Cycle 1
Health 2025-06-21 · Fire 2025-06-21
9 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Lehigh Acres, FL
Lehigh Acres Healthcare & Rehab Center
2-star overall rating with 1-star inspections with $132,889 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1550 Lee Boulevard, Lehigh Acres, FL
(239) 369-2194
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
128
Certified beds
Average residents
118
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Gold Fl Trust Ii
Operator or chain grouping
Approved since
1986-01-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
46 facilities
Chain averages 3 overall / 3 health / 3 staffing / 5 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
0.73
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.26
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.86
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.60
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.42
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.67
CMS adjusted RN staffing hours
Adjusted total hours
3.51
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
63%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,457
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.21
Composite VBP score used to determine payment impact.
Payment multiplier
0.9973
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.31
Baseline 20.44% · Performance 18.04% · Measure score 7.31 · Achievement 7.31 · Improvement 6.52
Healthcare-associated infections
3.64
Baseline 6.89% · Performance 6.75% · Measure score 3.64 · Achievement 3.64 · Improvement 0.25
Total nurse turnover
5.01
Baseline 50.79% · Performance 43.20% · Measure score 5.01 · Achievement 5.01 · Improvement 2.43
Adjusted total nurse staffing
1.72
Baseline 3.86 hours · Performance 3.57 hours · Measure score 1.72 · Achievement 1.72 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.32% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 207 · Observed rate 10.63% · Lower 95% interval 8.94% |
| Discharge to community | 63.02% |
50.57%
12.5 pts better
|
Better than the National Rate · Eligible stays 199 · Observed rate 61.31% · Lower 95% interval 54.55% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.11% |
95.27%
3.8 pts better
|
Numerator 222 · Denominator 224 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 224 |
| Discharge self-care score | 54% |
53.69%
0.3 pts better
|
Numerator 81 · Denominator 150 |
| Discharge mobility score | 38.67% |
50.94%
12.3 pts worse
|
Numerator 58 · Denominator 150 |
| Pressure ulcers or injuries, new or worsened | 1.34% |
2.29%
0.9 pts better
|
Numerator 3 · Denominator 224 · Adjusted rate 1.24% |
| Healthcare-associated infections requiring hospitalization | 6.75% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 127 · Observed rate 5.51% · Lower 95% interval 3.38% |
| Staff COVID-19 vaccination coverage | 23.26% |
8.2%
15.1 pts better
|
Numerator 20 · Denominator 86 |
| Staff flu vaccination coverage | 18.22% |
42%
23.8 pts worse
|
Numerator 41 · Denominator 225 |
| Discharge function score | 54% |
56.45%
2.5 pts worse
|
Numerator 81 · Denominator 150 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 66 · Denominator 66 |
| Transfer of health information to patient | 99.14% |
96.28%
2.9 pts better
|
Numerator 115 · Denominator 116 |
| Resident COVID-19 vaccinations up to date | 11.72% |
25.2%
13.5 pts worse
|
Numerator 15 · Denominator 128 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.5 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.2
0.3 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.6 · Expected 1.2 · 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 | 3.4% |
2.6%
0.8 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 2.6% · Q3 2.4% · Q4 5.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.1% |
3.7%
0.6 pts better
|
11.4%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 2.8% · Q3 2.6% · Q4 2.8% · 4Q avg 3.1% |
| Percentage of long-stay residents who lose too much weight | 6.2% |
5.9%
0.3 pts worse
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.5% · Q3 15.6% · Q4 6.3% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 1.9% |
15.7%
13.8 pts better
|
19.6%
17.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.5% · Q3 1.5% · Q4 3.1% · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.6% |
9.8%
2.8 pts worse
|
16.7%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 13.8% · Q3 13.4% · Q4 8.3% · 4Q avg 12.6% · 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 | 1.5% |
11.7%
10.2 pts better
|
16.3%
14.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 6.1% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 1.2% |
9.8%
8.6 pts better
|
14.9%
13.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 3.2% · Q4 0.0% · 4Q avg 1.2% · 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 | 1.2% |
12.5%
11.3 pts better
|
19.8%
18.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.3% · Q3 1.2% · Q4 1.2% · 4Q avg 1.2% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
5.1%
1.5 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 4.0% · Q3 5.2% · Q4 2.9% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.9% |
94.3%
5.6 pts better
|
81.7%
18.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.6% · 4Q avg 99.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.8% |
9.3%
0.5 pts better
|
12.0%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.8% · Observed 8.4% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.5%
0.3 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 1.7% · Q3 1.9% · Q4 0.7% · 4Q avg 1.2% · 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 | 26.3% |
26.2%
0.1 pts worse
|
23.9%
2.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.3% · Observed 25.8% · Expected 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-26 · Fire 2023-10-26
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-02-10 · Fire 2022-02-10
11 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-06-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-25
F · Potential for more than minimal harm
2022-02-10
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2022-03-08
F · Potential for more than minimal harm
2022-02-10
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-08-08
F · Potential for more than minimal harm
2022-02-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-03-08
D · Potential for more than minimal harm
2022-02-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-03-08
Inspection history
Recent health citations
G · Actual harm
2025-08-25
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 2025-09-18
K · Immediate jeopardy
2025-06-21
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 2025-07-25
K · Immediate jeopardy
2025-06-21
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-07-25
K · Immediate jeopardy
2025-06-21
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-07-25
E · Potential for more than minimal harm
2025-06-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-06-21
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 2025-07-25
D · Potential for more than minimal harm
2025-06-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-06-21
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-06-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-25
J · Immediate jeopardy
2024-08-24
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-09-18
J · Immediate jeopardy
2024-08-24
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 2024-09-18
F · Potential for more than minimal harm
2024-08-24
F843 · Administration Deficiencies
Health
Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.
Corrected 2024-09-18
D · Potential for more than minimal harm
2024-08-24
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-09-18
E · Potential for more than minimal harm
2023-10-26
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 2023-11-26
E · Potential for more than minimal harm
2023-10-26
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 2023-11-26
D · Potential for more than minimal harm
2023-10-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-26
D · Potential for more than minimal harm
2023-10-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-26
D · Potential for more than minimal harm
2023-10-26
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-11-26
D · Potential for more than minimal harm
2023-10-26
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-11-26
D · Potential for more than minimal harm
2023-10-26
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-11-26
E · Potential for more than minimal harm
2023-03-16
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 2023-04-16
D · Potential for more than minimal harm
2023-03-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-16
F · Potential for more than minimal harm
2022-02-10
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 2022-03-10
F · Potential for more than minimal harm
2022-02-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-05
E · Potential for more than minimal harm
2022-02-10
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-03-10
D · Potential for more than minimal harm
2022-02-10
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 2022-03-10
D · Potential for more than minimal harm
2022-02-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-03-10
D · Potential for more than minimal harm
2022-02-10
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2022-03-10
D · Potential for more than minimal harm
2022-02-10
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 2022-03-10
D · Potential for more than minimal harm
2022-02-10
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2022-03-10
D · Potential for more than minimal harm
2022-02-10
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 2022-03-10
Penalties and ownership
What sits behind the stars
$71,435
2025-06-21
Fine
Fine · fine $71,435
Fine
$61,454
2024-08-24
Fine
Fine · fine $61,454
Fine
Ownership
Lehigh Acres SNF Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Copper Fl Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
Fl Master Opco Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Gold Fl Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
Shelby, Jack
Corporate Officer · Individual
Silver Fl Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
Stanfield, Dawn
W-2 Managing Employee · Individual
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#3
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