Cycle 1
Health 2025-04-03 · Fire 2025-04-03
10 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fort Myers, FL
Fort Myers Rehabilitation And Nursing Center
3-star overall rating with 2-star inspections with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
7173 Cypress Drive Sw, Fort Myers, FL
(239) 936-0203
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
120
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Jonathan Bleier
Operator or chain grouping
Approved since
1983-01-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
18 facilities
Chain averages 3 overall / 2 health / 3 staffing / 4 quality stars
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
0.85
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.75
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.45
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.71
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.75
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.60
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
0.83
CMS adjusted RN staffing hours
Adjusted total hours
4.36
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
29%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,761
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.79
Composite VBP score used to determine payment impact.
Payment multiplier
0.9867
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.89% · Performance 22.66% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.91% · Performance 8.29% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
8.18
Baseline 34.15% · Performance 30.23% · Measure score 8.18 · Achievement 8.18 · Improvement 3.71
Adjusted total nurse staffing
4.53
Baseline 4.46 hours · Performance 4.37 hours · Measure score 4.53 · Achievement 4.53 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.64% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 214 · Observed rate 9.35% · Lower 95% interval 6.98% |
| Discharge to community | 50.24% |
50.57%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 154 · Observed rate 40.26% · Lower 95% interval 41.99% |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 269 · Denominator 269 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 269 |
| Discharge self-care score | 64.33% |
53.69%
10.6 pts better
|
Numerator 101 · Denominator 157 |
| Discharge mobility score | 50.96% |
50.94%
About the same
|
Numerator 80 · Denominator 157 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 269 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.29% |
7.12%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 137 · Observed rate 10.95% · Lower 95% interval 5.26% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 190 |
| Staff flu vaccination coverage | 8.5% |
42%
33.5 pts worse
|
Numerator 17 · Denominator 200 |
| Discharge function score | 63.69% |
56.45%
7.2 pts better
|
Numerator 100 · Denominator 157 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 95 · Denominator 95 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 85 · Denominator 85 |
| Resident COVID-19 vaccinations up to date | 26.35% |
25.2%
1.2 pts better
|
Numerator 39 · Denominator 148 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.1
0.4 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 2.0 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.2
0.4 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.7 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.8%
2.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 0.7% |
2.6%
1.9 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.9% · Q3 0.9% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
3.7%
3.2 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 0.0% · Q4 1.1% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 7.3% |
5.9%
1.4 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 3.8% · Q3 8.9% · Q4 6.7% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.6% |
15.7%
0.9 pts worse
|
19.6%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.2% · Q2 17.4% · Q3 14.3% · Q4 13.9% · 4Q avg 16.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.3% |
9.8%
8.5 pts worse
|
16.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 16.9% · Q3 15.5% · Q4 12.5% · 4Q avg 18.3% · 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 | 3.4% |
11.7%
8.3 pts better
|
16.3%
12.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 0.0% · Q3 0.0% · Q4 2.8% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.5% |
9.8%
6.3 pts better
|
14.9%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 2.5% · Q3 5.0% · Q4 2.7% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.4%
0.3 pts worse
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.0% · Q3 0.8% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
0.8%
0.2 pts worse
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 2.0% · Q3 1.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 3.4% |
12.5%
9.1 pts better
|
19.8%
16.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 2.2% · Q3 1.0% · Q4 5.4% · 4Q avg 3.4% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
5.1%
3 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.8% · Q3 3.3% · Q4 3.7% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.3%
5.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.0% |
9.3%
3.7 pts worse
|
12.0%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.0% · Observed 14.1% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 6.2% |
1.5%
4.7 pts worse
|
1.6%
4.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 3.1% · Q3 6.8% · Q4 9.9% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.7%
5.3 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.7% |
26.2%
6.5 pts worse
|
23.9%
8.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.7% · Observed 33.3% · Expected 24.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-18 · Fire 2022-08-18
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2021-02-26 · Fire 2021-02-26
8 health deficiencies
Top issue: Resident Rights (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-03
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-05-08
F · Potential for more than minimal harm
2025-04-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-08
D · Potential for more than minimal harm
2025-04-03
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-05-08
D · Potential for more than minimal harm
2025-04-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-08
D · Potential for more than minimal harm
2025-04-03
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2025-05-08
F · Potential for more than minimal harm
2022-08-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-09-18
F · Potential for more than minimal harm
2022-08-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-09-18
F · Potential for more than minimal harm
2022-08-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-09-18
F · Potential for more than minimal harm
2022-08-18
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2022-09-18
D · Potential for more than minimal harm
2022-08-18
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-09-18
F · Potential for more than minimal harm
2021-02-26
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-03-28
E · Potential for more than minimal harm
2021-02-26
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2021-03-28
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-03
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 2025-05-10
E · Potential for more than minimal harm
2025-04-03
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-05-10
E · Potential for more than minimal harm
2025-04-03
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2025-05-10
E · Potential for more than minimal harm
2025-04-03
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 2025-05-10
E · Potential for more than minimal harm
2025-04-03
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-05-10
D · Potential for more than minimal harm
2025-04-03
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 2025-05-10
D · Potential for more than minimal harm
2025-04-03
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-05-10
D · Potential for more than minimal harm
2025-04-03
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 2025-05-10
D · Potential for more than minimal harm
2025-04-03
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-05-10
D · Potential for more than minimal harm
2025-04-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-10
E · Potential for more than minimal harm
2022-08-18
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2022-09-18
E · Potential for more than minimal harm
2022-08-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-09-18
E · Potential for more than minimal harm
2022-08-18
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 2022-11-11
D · Potential for more than minimal harm
2022-08-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-09-18
C · Minimal harm
2022-08-18
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2022-09-18
K · Immediate jeopardy
2021-02-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-03-28
E · Potential for more than minimal harm
2021-02-26
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2021-03-28
E · Potential for more than minimal harm
2021-02-26
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 2021-03-28
E · Potential for more than minimal harm
2021-02-26
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 2021-03-28
E · Potential for more than minimal harm
2021-02-26
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2021-03-28
E · Potential for more than minimal harm
2021-02-26
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2021-03-28
D · Potential for more than minimal harm
2021-02-26
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-03-28
D · Potential for more than minimal harm
2021-02-26
F917 · Environmental Deficiencies
Health
Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.
Corrected 2021-03-28
Penalties and ownership
What sits behind the stars
Ownership
Bleier, Jonathan
5% Or Greater Indirect Ownership Interest · Individual
Bleier, Jonathan
Corporate Officer · Individual
Breder, Tobias
Operational/Managerial Control · Individual
Breder, Tobias
W-2 Managing Employee · Individual
Hollywood Hills Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
Nearby options
Other facilities in reach
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2-star overall rating with 2-star inspections with $16,801 in total fines with 10 recent health deficiencies
#2
Ambassador Healthcare At College Park
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1-star overall rating with 1-star inspections with abuse icon flag with $78,430 in total fines with 15 recent health deficiencies
#3
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
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