Lehigh Acres Healthcare & Rehab Center

In the surveyor’s words

From the most serious findings on record at Lehigh Acres Healthcare & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jun 21, 2025

  Based on observations, record review, residents and staff interviews, the facility failed to implement ongoing training, competencies and supervision of staff to ensure the safe use of manual and mechanical lifts to prevent avoidable accidents for 1 (Resident #48) of 29 residents care planned for manual or mechanical lift transfer. Resident #48's diagnoses included obesity, history of multiple strokes and functional limitation in range of motion of upper and lower extremities on one side. On 5/2/25 the nurse on duty documented the resident was crying and in a lot of pain. Her ankle was swollen with purple bruising. Resident #48 reported she sustained the injury to her foot the previous night when the lift was used wrong. Resident #48 was diagnosed with a fracture of the left heel bone. […]

• Immediate jeopardy, patternF726Jun 21, 2025

  Based on observations, record reviews, residents and staff interviews, the facility failed to ensure nursing staff had the appropriate training and competencies to prevent avoidable accidents during residents' transfer with manual and/or mechanical lifts for 1 (Resident #48) of 29 residents care planned for transfers with manual or mechanical lifts. Resident #48 diagnoses included a history of multiple strokes, obesity and unilateral functional limitation in range of motion of upper and lower extremities. Resident #48 was care planned for the use of a (brand name) manual sit-to-stand lift for transfers. On 5/2/25 the nurse on duty documented the resident was crying and in a lot of pain. Her ankle was swollen with purple bruising. […]

• Immediate jeopardy, patternF835Jun 21, 2025

  Based on observations, record review, residents and staff interviews, the facility's Administration failed to utilize its resources effectively to maintain oversight and ensure staff were trained and competent in the safe use of manual and mechanical lifts to transfer residents and appropriately respond to residents' incidents for 1 (Resident #48) of 29 residents care planned for manual or mechanical lifts for transfers. Resident #48 diagnoses included a history of multiple strokes, obesity and unilateral functional limitation in range of motion of upper and lower extremities. Resident #48 was care planned for the use of a manual sit-to-stand lift for transfers. On 5/2/25 the nurse on duty documented the resident was crying and in a lot of pain. Her ankle was swollen with purple bruising. […]

• Immediate jeopardy, isolatedF600Aug 24, 2024

  Based on clinical record review, review of facility policies and procedures, resident representative and staff interviews, the facility failed to protect the residents' right to be free from neglect. The facility failed to re-evaluate the risk for elopement and implement adequate supervision to prevent unsafe wandering and elopement for 1 (Resident #1) of 3 sampled residents reviewed with severe cognitive impairment, confusion, and decreased safety awareness. Resident #1 was a vulnerable adult admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, cognitive communication deficit, and generalized muscle weakness. On 8/16/24, documentation in the nursing progress notes indicated Resident #1 was confused, wandering and said he wanted to go down the street to his house. […]

• Immediate jeopardy, isolatedF689Aug 24, 2024

  Based on clinical record review, review of facility's policies and procedures, resident representative and staff interviews the facility failed to recognize risk factors for elopement and adequately supervise 1 (Resident #1) of 3 sampled residents with severe cognitive impairment, confusion, wandering behavior and poor safety awareness who expressed desire to leave the facility. On 8/16/24 at approximately 7:30 p.m., Resident #1 who was confused, wandered, and voiced desire to leave the facility sat in the front lobby with a bag of clothes. The receptionist unlocked the door to the front lobby and allowed the resident to leave the facility without verifying his identity. […]