Cycle 1
Health 2023-10-19 · Fire 2023-10-19
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Estero, FL
Life Care Center Of Estero
5-star overall rating with 3-star inspections with $8,034 in total fines with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
3850 Williams Road, Estero, FL
(239) 495-4000
Overall
5 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
155
Certified beds
Average residents
141
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Life Care Centers Of America
Operator or chain grouping
Approved since
2003-10-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
194 facilities
Chain averages 4 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
0.97
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.54
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.32
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.83
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.51
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.46
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
1.11
CMS adjusted RN staffing hours
Adjusted total hours
4.38
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
21%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,483
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.81
Composite VBP score used to determine payment impact.
Payment multiplier
0.9928
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.49% · Performance 23.49% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.15
Baseline 5.25% · Performance 7.19% · Measure score 2.15 · Achievement 2.15 · Improvement 0
Total nurse turnover
10
Baseline 26.98% · Performance 21.14% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
3.78
Baseline 4.16 hours · Performance 4.15 hours · Measure score 3.78 · Achievement 3.78 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.97% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 590 · Observed rate 10.51% · Lower 95% interval 9.77% |
| Discharge to community | 56.58% |
50.57%
6 pts better
|
Better than the National Rate · Eligible stays 565 · Observed rate 54.16% · Lower 95% interval 53.87% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 449 · Denominator 449 |
| Falls with major injury | 1.34% |
0.77%
0.6 pts worse
|
Numerator 6 · Denominator 449 |
| Discharge self-care score | 80.26% |
53.69%
26.6 pts better
|
Numerator 183 · Denominator 228 |
| Discharge mobility score | 67.54% |
50.94%
16.6 pts better
|
Numerator 154 · Denominator 228 |
| Pressure ulcers or injuries, new or worsened | 1.34% |
2.29%
0.9 pts better
|
Numerator 6 · Denominator 449 · Adjusted rate 1.2% |
| Healthcare-associated infections requiring hospitalization | 7.19% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 372 · Observed rate 6.18% · Lower 95% interval 5.08% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 207 |
| Staff flu vaccination coverage | 27.5% |
42%
14.5 pts worse
|
Numerator 66 · Denominator 240 |
| Discharge function score | 79.39% |
56.45%
22.9 pts better
|
Numerator 181 · Denominator 228 |
| Transfer of health information to provider | 98.97% |
95.95%
3 pts better
|
Numerator 96 · Denominator 97 |
| Transfer of health information to patient | 97.53% |
96.28%
1.2 pts better
|
Numerator 276 · Denominator 283 |
| Resident COVID-19 vaccinations up to date | 10.93% |
25.2%
14.3 pts worse
|
Numerator 27 · Denominator 247 |
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 1.6 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.2
0.5 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.4 · 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 | 3.5% |
2.6%
0.9 pts worse
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 5.5% · Q3 2.9% · Q4 1.9% · 4Q avg 3.5% · 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 | 6.4% |
5.9%
0.5 pts worse
|
5.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 7.1% · Q3 5.1% · Q4 3.6% · 4Q avg 6.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.5% |
15.7%
3.8 pts worse
|
19.6%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 17.2% · Q3 21.7% · Q4 22.1% · 4Q avg 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.4% |
9.8%
0.6 pts worse
|
16.7%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 12.5% · Q3 8.1% · Q4 5.2% · 4Q avg 10.4% · 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 | 8.0% |
11.7%
3.7 pts better
|
16.3%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 11.7% · Q3 6.0% · Q4 3.9% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.9% |
9.8%
3.9 pts better
|
14.9%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 9.0% · Q3 5.2% · Q4 2.4% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.4%
0.2 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
0.8%
0.6 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.7% |
12.5%
3.8 pts better
|
19.8%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 9.2% · Q3 4.5% · Q4 4.4% · 4Q avg 8.7% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
5.1%
1.2 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 3.7% · Q3 3.9% · Q4 3.0% · 4Q avg 3.9% · 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 99.7% · 4Q avg 99.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.0% |
9.3%
2.3 pts better
|
12.0%
5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.0% · Observed 6.2% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.5%
0.6 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.3% · Q3 0.9% · Q4 0.5% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.9% |
94.7%
3.2 pts better
|
79.7%
18.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.6% |
26.2%
1.4 pts worse
|
23.9%
3.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.6% · Observed 22.6% · Expected 19.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-12-09 · Fire 2021-12-09
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2020-02-13 · Fire 2020-02-13
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-10-19
K902 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of medical gas and medical vacuum systems.
Corrected 2023-11-19
E · Potential for more than minimal harm
2023-10-19
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-11-19
D · Potential for more than minimal harm
2021-12-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-01-09
D · Potential for more than minimal harm
2021-12-09
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2022-01-09
F · Potential for more than minimal harm
2020-02-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-03-13
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-07-09
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-09
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-09
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-08-09
E · Potential for more than minimal harm
2023-10-19
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 2023-11-19
E · Potential for more than minimal harm
2023-10-19
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-11-19
E · Potential for more than minimal harm
2023-10-19
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 2023-11-19
D · Potential for more than minimal harm
2023-10-19
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-11-19
D · Potential for more than minimal harm
2023-10-19
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 2023-11-19
D · Potential for more than minimal harm
2021-12-09
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 2022-01-09
E · Potential for more than minimal harm
2020-02-13
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2020-03-13
E · Potential for more than minimal harm
2020-02-13
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 2020-03-13
D · Potential for more than minimal harm
2020-02-13
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2020-03-13
D · Potential for more than minimal harm
2020-02-13
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 2020-03-13
Penalties and ownership
What sits behind the stars
$4,017
2024-07-09
Fine
Fine · fine $4,017
Fine
$4,017
2024-07-09
Fine
Fine · fine $4,017
Fine
Ownership
Breuler, James
W-2 Managing Employee · Individual
Cross, Cindy
Corporate Officer · Individual
Life Care Centers Of America, Inc.
Operational/Managerial Control · Organization
Preston, Forrest
5% Or Greater Direct Ownership Interest · Individual
Thurmond, Joan
Corporate Officer · Individual
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