Cycle 1
Health 2024-11-15 · Fire 2024-11-15
10 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fort Myers, FL
Cedarbrook Health And Rehabilitation Center
2-star overall rating with 2-star inspections with $16,801 in total fines with 10 recent health deficiencies
1600 Matthew Drive, Fort Myers, FL
(239) 275-6067
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
99
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1991-04-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.74
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.59
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.03
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.36
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.08
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.66
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.79
CMS adjusted RN staffing hours
Adjusted total hours
3.58
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
71%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,590
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.19
Composite VBP score used to determine payment impact.
Payment multiplier
0.9831
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.43
Baseline 22.36% · Performance 21.87% · Measure score 0.43 · Achievement 0 · Improvement 0.43
Healthcare-associated infections
0
Baseline 6.70% · Performance 8.16% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
7.33
Baseline 53.76% · Performance 33.71% · Measure score 7.33 · Achievement 7.33 · Improvement 6.44
Adjusted total nurse staffing
1.51
Baseline 3.66 hours · Performance 3.51 hours · Measure score 1.51 · Achievement 1.51 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13% |
10.72%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 131 · Observed rate 17.56% · Lower 95% interval 9.3% |
| Discharge to community | 46.79% |
50.57%
3.8 pts worse
|
No Different than the National Rate · Eligible stays 122 · Observed rate 38.52% · Lower 95% interval 39.3% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 111 · Denominator 111 |
| Falls with major injury | 1.8% |
0.77%
1 pts worse
|
Numerator 2 · Denominator 111 |
| Discharge self-care score | 39.71% |
53.69%
14 pts worse
|
Numerator 27 · Denominator 68 |
| Discharge mobility score | 39.71% |
50.94%
11.2 pts worse
|
Numerator 27 · Denominator 68 |
| Pressure ulcers or injuries, new or worsened | 5.41% |
2.29%
3.1 pts worse
|
Numerator 6 · Denominator 111 · Adjusted rate 3.84% |
| Healthcare-associated infections requiring hospitalization | 8.17% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 68 · Observed rate 10.29% · Lower 95% interval 4.54% |
| Staff COVID-19 vaccination coverage | 72.55% |
8.2%
64.3 pts better
|
Numerator 111 · Denominator 153 |
| Staff flu vaccination coverage | 1.94% |
42%
40.1 pts worse
|
Numerator 3 · Denominator 155 |
| Discharge function score | 44.12% |
56.45%
12.3 pts worse
|
Numerator 30 · Denominator 68 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 41 · Denominator 41 |
| Transfer of health information to patient | 97.37% |
96.28%
1.1 pts better
|
Numerator 37 · Denominator 38 |
| Resident COVID-19 vaccinations up to date | 13.33% |
25.2%
11.9 pts worse
|
Numerator 8 · Denominator 60 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.3 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.2
0.8 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.4 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
97.8%
1 pts worse
|
93.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 91.4% · Q2 100.0% · Q3 98.8% · Q4 97.6% · 4Q avg 96.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
99.2%
0.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
2.6%
About the same
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 2.3% · Q3 0.0% · Q4 1.2% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
3.7%
3.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 7.6% |
5.9%
1.7 pts worse
|
5.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 6.2% · Q3 9.6% · Q4 11.7% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.2% |
15.7%
2.5 pts better
|
19.6%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 12.5% · Q3 13.7% · Q4 13.0% · 4Q avg 13.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.0% |
9.8%
2.8 pts better
|
16.7%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 8.5% · Q3 7.5% · Q4 4.3% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.0% |
11.7%
6.7 pts better
|
16.3%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 14.0% · Q3 0.0% · Q4 0.0% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.4% |
9.8%
4.4 pts better
|
14.9%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 6.9% · Q3 0.0% · Q4 0.0% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.9% |
12.5%
13.4 pts worse
|
19.8%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 22.0% · Q3 26.4% · Q4 29.1% · 4Q avg 25.9% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
5.1%
0.3 pts worse
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 7.6% · Q3 5.0% · Q4 3.4% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.8% |
94.3%
4.5 pts worse
|
81.7%
8.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.5% · Q2 91.6% · Q3 90.8% · Q4 80.8% · 4Q avg 89.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.6% |
9.3%
3.3 pts worse
|
12.0%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.6% · Observed 12.2% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.5% |
94.7%
0.2 pts worse
|
79.7%
14.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.6% |
26.2%
2.6 pts better
|
23.9%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.6% · Observed 22.2% · Expected 22.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-09 · Fire 2023-02-09
12 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
10 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Cycle 3
Health 2021-06-10 · Fire 2021-06-10
10 health deficiencies
Top issue: Resident Rights (3 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-02-09
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-09
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-09
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-09
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-09
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-09
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2023-03-09
F · Potential for more than minimal harm
2023-02-09
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2023-03-09
E · Potential for more than minimal harm
2023-02-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-09
D · Potential for more than minimal harm
2023-02-09
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-03-09
D · Potential for more than minimal harm
2023-02-09
K917 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure electrical receptacles or cover plates have distinctive color or marking.
Corrected 2023-03-09
F · Potential for more than minimal harm
2021-06-10
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2021-07-11
Inspection history
Recent health citations
G · Actual harm
2024-11-15
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-12-14
E · Potential for more than minimal harm
2024-11-15
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-12-14
E · Potential for more than minimal harm
2024-11-15
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-12-14
E · Potential for more than minimal harm
2024-11-15
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-15
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-15
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-15
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-15
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-15
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-15
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2024-12-14
D · Potential for more than minimal harm
2023-04-18
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-05-18
D · Potential for more than minimal harm
2023-04-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-18
E · Potential for more than minimal harm
2023-02-09
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-03-17
E · Potential for more than minimal harm
2023-02-09
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-03-17
E · Potential for more than minimal harm
2023-02-09
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-02-09
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-02-09
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-03-28
D · Potential for more than minimal harm
2023-02-09
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-02-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-02-09
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-02-09
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-02-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-02-09
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-03-17
F · Potential for more than minimal harm
2021-06-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-07-10
F · Potential for more than minimal harm
2021-06-10
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2021-07-10
F · Potential for more than minimal harm
2021-06-10
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2021-07-10
D · Potential for more than minimal harm
2021-06-10
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2021-07-10
D · Potential for more than minimal harm
2021-06-10
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2021-07-10
D · Potential for more than minimal harm
2021-06-10
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2021-07-10
D · Potential for more than minimal harm
2021-06-10
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-07-10
D · Potential for more than minimal harm
2021-06-10
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-07-10
Penalties and ownership
What sits behind the stars
$16,801
2024-11-15
Fine
Fine · fine $16,801
Fine
Ownership
Cedarbrook Rehab Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Bf Cedarbrook Trust
5% Or Greater Indirect Ownership Interest · Organization
Lf Cedarbrook Trust
5% Or Greater Indirect Ownership Interest · Organization
Atkinstall, Alicia
Operational/Managerial Control · Individual
Aviles, Ursula
Operational/Managerial Control · Individual
Martinez Irizarry, Alfonso
Operational/Managerial Control · Individual
Soltis, Erin
Operational/Managerial Control · Individual
Wildes, Donna
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Page Rehabilitation And Healthcare Center
Fort Myers, FL
2-star overall rating with 1-star inspections with $195,442 in total fines with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Fort Myers Rehabilitation And Nursing Center
Fort Myers, FL
3-star overall rating with 2-star inspections with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Aspire At Evans
Fort Myers, FL
1-star overall rating with 1-star inspections with abuse icon flag with $50,028 in total fines with 18 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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