1550 Lee Boulevard, Lehigh Acres, FL 33936 · Lee County · (239) 369-2194
128 certified beds, about 122 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1986
CMS Care Compare ratings, data as of September 1, 2026 · CCN 105522 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on June 21, 2025, inspectors cited 8 health deficiencies (the Florida average is 7.1, the national average 9.2).
Of 29 health citations since February 2022, 6 were rated as actual harm or immediate jeopardy to residents (5 immediate jeopardy).
CMS lists 3 fines totaling $149,609 in the last three years; the largest was $71,435, and the latest is dated August 25, 2025.
Nurses and nurse aides worked 4.08 hours per resident per day, against 3.82 across Florida and 3.86 nationally. Registered nurses accounted for 0.65 of those hours.
43.2% of nursing staff left within the year CMS measured (Florida average 41.4%).
CMS links it to Gold Fl Trust II, an affiliated group of 36 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 29 health citations on file.
Inspectors wroteBased on observation, record review, review of facility's policy and procedure, staff and resident interview the facility failed to follow safety precautions during transportation to doctor's appointments to prevent avoidable accident and injury to 1 (Resident #900) of 2 residents reviewed.
Inspectors wroteBased 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. [...]
Inspectors wroteBased 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. Resident #48 reported she sustained the injury to her foot the previous night when the lift was used wrong. [...]
Inspectors wroteBased 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. [...]
Inspectors wroteOn 6/17/25 at 10:15 a.m., the Wound Care Nurse was observed cleaning Resident #60's open areas to the buttocks and sacrum. The Wound Care Nurse donned gloves and filled a wash basin with tap water. He added soap to the water from the wall mounted soap dispenser in the resident's shower. The Wound Care Nurse used a washcloth and the soapy water in the wash basin to clean the resident's open areas to the buttocks and sacrum. The Wound Care Nurse took the wash basin to the shared bathroom and rinsed it in the sink. He placed the wet, uncovered wash basin on the grab bar of the shared shower to dry. An uncovered, unlabeled urinal was observed hanging from the grab bar behind the toilet. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 (Residents #111 and #62) of 3 dependent residents reviewed for Activities of Daily Living received the necessary assistance for shaving per their preferences.
Inspectors wroteBased on observations, record review, resident and staff interviews, the facility failed to provide care and services to prevent the development and worsening of a pressure ulcer for 1 (Resident #60) of 2 residents reviewed who developed a pressure ulcer at the facility.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure 1 (Resident #76) of 3 residents reviewed for nutrition and weight loss received the prescribed diet for 2 of 3 meals observed, failed to ensure accurate documentation of resident's risk factors and interventions to prevent weight loss, and failed to ensure timely coordination when the resident experienced difficulty with chewing and swallowing food.
Inspectors wroteBased on record review, resident and staff interview and observations the facility failed to deliver the prescribed oxygen amount for 1 (Resident #60) of 6 residents sampled.
Inspectors wroteBased 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. The facility neglected to re-evaluate the risk for elopement and adequately supervise Resident #1. [...]
Inspectors wroteBased 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. The facility staff were not aware of the resident's exit until 8/16/24 at approximately 8:45 p.m. [...]
Inspectors wroteBased on record review and staff interview, the facility failed to have a written transfer agreement in effect with one or more hospitals approved for participation under the Medicaid and Medicare programs.
Inspectors wroteBased on record review, review of facility's policies and procedures, and staff interviews, the facility failed to ensure an allegation of neglect was reported to the State Survey Agency within the prescribed timeframe for 1 (Resident #1) of 3 residents reviewed.
Inspectors wroteBased on interviews, and review of job descriptions the facility failed to designate a licensed nurse to serve as a charge nurse on each tour of duty as required.
Inspectors wroteBased on observation, interview and record review, the facility failed to have a system in place to ensure an accurate inventory of controlled medications returned for disposition.
Inspectors wroteBased on observation, staff interviews and medical record review, the facility failed to ensure the accurate nursing skin evaluation and coordination of care between dietary and physician services for nutritional supplements for 1 (Resident #45) of 3 residents reviewed for pressure wounds.
Inspectors wroteBased on observation, staff interviews and medical record review, the facility failed to ensure the accurate nursing skin evaluation and coordination of care between dietary and physician services for nutritional supplements for 1 (Resident #45) of 3 residents reviewed for pressure wounds.
Inspectors wroteBased on observation, clinical record review, and interviews the facility failed to monitor the fluid intake of 1 (Resident #61) of 3 resident sampled with a physician order for fluid restriction.
Inspectors wroteBased on review of employee files, staff interviews, and facility policy review the facility failed to complete an annual performance review and provide in-service education based on the outcome of the reviews for 1 ( Staff G) of 3 Certified Nursing Assistants (CNAs) reviewed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate less than 5%. 25 opportunities were observed with three nurses and three residents. Three medication errors were observed resulting in a medication error rate of 12%.
Inspectors wroteBased on observation, record review, and staff interview, the facility failed to provide a clean, safe, and sanitary environment in the kitchen, and 3 of 3 nourishment rooms observed by not having clean food preparation and storage equipment. This failure had the potential to cause food borne illness in residents receiving an oral diet.
Inspectors wroteBased on record review and staff interview the facility failed to maintain documentation of a water management program to minimize the risk of waterborne pathogens, including Legionella.
Inspectors wroteBased on observation, record review and staff interview the facility failed to administer medication according to the manufacturer's specification and physician's orders for 2 (Resident #50 and #349) of 3 residents observed for medication administration. Three Licensed nurses and 26 opportunities were observed. Four medication errors were identified resulting in a 15.38 % error rate.
Inspectors wroteBased on observation, staff and resident interviews, the facility failed to maintain a sanitary, damage free, and homelike environment for 6 (#83, #300, #93, #95, #54 and #72) of 24 residents reviewed and 3 (room [ROOM NUMBER], #224 and #226) of 17 rooms observed.
Inspectors wroteBased on record review, and staff interview the facility failed to ensure accuracy of the Minimum Data Set (MDS) assessment related to falls for 1 (Residents #60) of 3 residents reviewed for falls. This has the potential to lead to delayed care planning and services for the resident affected.
Inspectors wroteBased on interview and record review the facility failed to ensure they arranged for a follow up re-evaluation with the ophthalmologist as required for 1 (Resident #94) of 1 resident who had visual complications. The failure to arrange and ensure follow-up ophthalmologist visits are conducted timely has the potential to lead a loss of vision and a deterioration of the resident's quality of life.
Inspectors wroteBased on observation, record review, staff, and resident interviews the facility failed to identify and ensure safe storage of medications for 2 (Resident #12 and #83) of 22 residents reviewed for medication storage. This has the potential for other residents to have access to medications that can cause them harm.
Inspectors wroteBased on record review, staff and resident interviews, the facility failed to assist in obtaining routine dental services for 1 (Resident #7) of 7 residents sampled for provision of dental services.
Inspectors wroteBased on observation, record review, resident and staff interview the facility failed to distribute meal in a manner to ensure 1 (Resident #3) of 2 residents observed received the correct meal to accommodate resident's documented allergies and preferences.
5 fire safety citations on file: 1 on June 21, 2025, 4 on February 10, 2022.
| Date | Penalty | Amount or length |
|---|---|---|
| August 25, 2025 | Fine | $16,720 |
| June 21, 2025 | Fine | $71,435 |
| August 24, 2024 | Fine | $61,454 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Florida | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 4.08 | 3.82 | 3.86 |
| Registered nurses | 0.65 | 0.73 | 0.69 |
| All nursing staff on weekends | 3.53 | 3.49 | 3.42 |
| Nurse aides | 2.50 | ||
| Licensed practical nurses | 0.92 | ||
| Nursing staff turnover (share who left in a year) | 43.2% | 41.4% | 45.8% |
| Registered nurse turnover | 60.7% | 46.0% | 42.9% |
| Administrators who left | 0 |
CMS expects 4.01 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.30 on weekdays and 3.53 on weekends, 18% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.80 in April to June 2025 to 4.08 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 4.08 | 0.65 | 4.30 | 3.53 | 0.0% | 0 of 90 | 122 |
| Oct to Dec 2025 | 3.80 | 0.78 | 3.96 | 3.40 | 0.3% | 0 of 92 | 116 |
| Jul to Sep 2025 | 3.86 | 0.73 | 4.03 | 3.42 | 0.0% | 0 of 92 | 118 |
| Apr to Jun 2025 | 3.80 | 0.75 | 3.97 | 3.39 | 0.0% | 0 of 91 | 119 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Florida, Jan to Mar 2026 | 3.76 | 0.70 | 3.90 | 3.44 | 1.1% | 0.2% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Florida, all employers | |||
| CNAs (nursing assistants) | $18.03 | $17.33 to $20.34 | 96,960 |
| LPNs and LVNs | $29.70 | $28.14 to $31.11 | 38,620 |
| Registered nurses | $40.48 | $37.82 to $48.64 | 229,940 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Florida | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 3.3 | 8.7 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.3 | 0.3 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.7 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 5.2 | 2.5 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.5 | 1.5 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 1.7 | 9.5 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 3.9 | 4.5 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 7.4 | 8.6 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 24.4 | 26.1 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 7.5 | 9.1 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.6 | 2.1 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.4 | 1.1 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Lehigh Acres Healthcare & Rehab Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (63.0% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
63.0% this home
Better than the national rate
US median of homes 51.5% · Florida: 169 better, 109 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 199 eligible stays.
11.3% this home
No different from the national rate
US median of homes 10.7% · Florida: 2 better, 35 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 207 eligible stays.
6.8% this home
No different from the national rate
US median of homes 7.1% · Florida: 6 better, 21 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 127 eligible stays.
58.9% this home
Median of homes: Florida55.1% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 168 residents counted.
0.4% this home
Median of homes: Florida0.6% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 252 residents counted.
2.6% this home
Median of homes: Florida1.3% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 252 residents counted.
99.2% this home
Median of homes: Florida97.7% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 126 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: LEHIGH ACRES HEALTHCARE & REHAB CENTER LLC. CMS links this home to Gold Fl Trust II, a group of 36 nursing homes averaging 3.4 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Lehigh Acres SNF Holdco LLC | 5% or greater direct ownership interest | Organization | 100% | 03/23/2022 |
| Fl Master Opco Holdco LLC | 5% or greater indirect ownership interest | Organization | 100% | 07/27/2022 |
| Stanfield, Dawn | W-2 managing employee | Individual | 07/27/2022 | |
| Shelby, Jack | Corporate officer | Individual | 07/27/2022 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
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