Lehigh Acres Healthcare & Rehab Center
1550 Lee Boulevard, Lehigh Acres, FL 33936 · Lee County · 128 certified beds · avg 122 residents/day · certified since Jan 7, 1986
SFF Candidate
Part of chain: GOLD FL TRUST II (36 facilities, chain avg rating 3.4★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Jun 21, 2025 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Jul 25, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Jun 21, 2025 · F-0726
The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Why it matters: Undertrained caregivers are more likely to miss warning signs and make care mistakes.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Jul 25, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Jun 21, 2025 · F-0835
The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents.
Why it matters: Poor administration often shows up as understaffing, supply shortages, and care problems across the whole facility.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Jul 25, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Aug 24, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Sep 18, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Aug 24, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Sep 18, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 25, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 18, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (29)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Aug 25, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jun 21, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jun 21, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| Jun 21, 2025 | ▲ K · Immediate jeopardy, repeated | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. |
| Jun 21, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jun 21, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jun 21, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jun 21, 2025 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Jun 21, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Aug 24, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Aug 24, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Aug 24, 2024 | F · Potential for harm, facility-wide | The facility did not have an agreement with at least one Medicare- or Medicaid-certified hospital to ensure residents can be transferred quickly when they need hospital care. · from a complaint |
| Aug 24, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Oct 26, 2023 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Oct 26, 2023 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Oct 26, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Oct 26, 2023 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Oct 26, 2023 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Oct 26, 2023 | D · Potential for harm, one-off | The facility did not observe each nurse aide's job performance or provide regular training as required. · from a complaint |
| Oct 26, 2023 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Feb 10, 2022 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Feb 10, 2022 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Feb 10, 2022 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Feb 10, 2022 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Feb 10, 2022 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Feb 10, 2022 | D · Potential for harm, one-off | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. |
| Feb 10, 2022 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 10, 2022 | D · Potential for harm, one-off | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. |
| Feb 10, 2022 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (7 → 8).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 9 | 0 | F |
| 2023 | 7 | 0 | E |
| 2024 | 4 | 2 | J ▲ |
| 2025 | 9 | 4 | K ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $149,609.
| Date | Type | Amount / length |
|---|---|---|
| Aug 25, 2025 | Fine | $16,720 |
| Jun 21, 2025 | Fine | $71,435 |
| Aug 24, 2024 | Fine | $61,454 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Florida avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.89 | 4.03 | 3.95 | top 49% in Florida; top 44% in the U.S. |
| Registered Nurse hours | 0.62 | 0.76 | 0.69 | bottom 44% in Florida; top 45% in the U.S. |
| Weekend total nurse staffing | 3.37 | 3.68 | 3.50 | bottom 30% in Florida; top 49% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.40 | 0.53 | 0.48 | bottom 41% in Florida; top 48% in the U.S. |
| Total nursing staff turnover (%) | 43.2 | 41.4 | 45.8 | bottom 46% in Florida; top 45% in the U.S. |
| RN turnover (%) | 60.7 | 46.0 | 42.9 | bottom 23% in Florida; bottom 20% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.08, RN 0.65, weekend 3.53. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 4/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| FL Master Opco Holdco LLC | Organization | 5% or Greater Indirect Ownership Interest | 100% | 07/27/2022 |
| Lehigh Acres SNF Holdco LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 03/23/2022 |
| Shelby, Jack | Individual | Corporate Officer | NOT APPLICABLE | 07/27/2022 |
| Stanfield, Dawn | Individual | W-2 Managing Employee | NOT APPLICABLE | 07/27/2022 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
- "What were the findings behind this administration citation, and what has leadership changed since?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Winkler Court | 10.7 mi | Fort Myers, FL | ★★☆☆☆ | 1/5 | |
| Eagleridge Health and Rehabilitation Center | 11.5 mi | Fort Myers, FL | ★★★☆☆ | 2/5 | abuse |
| Aspire at Evans | 12.3 mi | Fort Myers, FL | ★☆☆☆☆ | 1/5 | |
| Gulf Coast Medical Center Skilled Nursing Unit | 12.6 mi | Fort Myers, FL | ★★★★★ | 5/5 | |
| The Preserve | 12.8 mi | Fort Myers, FL | ★★★★★ | 5/5 | |
| Lee Memorial Hospital Skilled Nursing Unit | 13.1 mi | Fort Myers, FL | ★★★★★ | 5/5 | |
| Page Rehabilitation and Healthcare Center | 13.1 mi | Fort Myers, FL | ★★☆☆☆ | 1/5 | |
| Fort Myers Rehabilitation and Nursing Center | 13.4 mi | Fort Myers, FL | ★★☆☆☆ | 2/5 | |
| Cedarbrook Health and Rehabilitation Center | 13.7 mi | Fort Myers, FL | ★★★☆☆ | 2/5 | |
| Ambassador Healthcare at College Park | 14.7 mi | Fort Myers, FL | ★☆☆☆☆ | 1/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 105522.