Inspection·August 25, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based 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. The findings included:Review of the facility's policy and procedure for Securing Residents in Wheelchairs for Van Transport (no effective date) revealed, It is the policy of this facility to ensure the safe and secure transport of all residents traveling in wheelchairs. All residents must be properly secured suing approved wheelchair tie-downs in compliance with Americans with Disabilities Act (ADA) and National Highway Traffic Safety Administration (NHTSA) guidelines. Staff must follow the outlined procedures at all times to prevent accidents or injuries. Securing the wheelchair. Attach two front tie-downs to solid frame points on the wheelchair (not on the footrests or detachable parts). Attach two rear tie-downs to the rear frame of the wheelchair. Tighten all straps to remove slack and prevent movement. Securing the resident. Final Safety Check. Verify all four tie-down straps are tight and locked. Ensure the lap and shoulder belts are properly secured.On 8/22/25 at 9:10 a.m., during a tour of the facility, Resident #900 was observed in bed. The resident's left lower extremity was wrapped in bandages. Multiple scabbed wounds were observed to the resident's arms. In an interview Resident #900 said on 8/18/25, her wheelchair was not strapped in the facility's van, causing it to fall backwards during transportation and scrape the skin right off her leg. Resident #900 said, It scared the hell out of me. Resident #900 said the scabbed wounds to her arms were from the skin tears she sustained during the incident. On 8/22/25 at 9:25 a.m., in an interview related to Resident #900's injuries, the Assistant Director of Nursing (ADON) verified on 8/18/25 the resident's wheelchair fell backwards in the company's van during transportation to an appointment. She said the facility's driver stopped at a red traffic light. As the driver was taking off when the light turned green, the resident's wheelchair tilted, and Resident #900 fell backwards. Emergency Medical Services (EMS) were called but Resident #900 refused to go to the hospital for evaluation. On 8/22/25 at 9:37 a.m., in an interview Driver Staff A said he started employment at the facility on 7/29/25. He said on 8/18/25 at approximately 10:00 a.m., he picked up Resident #900 from a doctor's appointment. He placed the resident's wheelchair in the middle section of the van. He secured the wheelchair to the van with two tie-down straps to the back frame of the wheelchair and applied the seatbelt. As he was leaving a red light, he heard the resident yell from the back of the van. He pulled over. A State Trooper pulled right behind the van and asked if he needed assistance. He said the resident's wheelchair tipped back slowly. Resident #900 was still strapped to the wheelchair. He unstrapped Resident #900. EMS arrived and bandaged the resident's arms. The resident refused to go to the hospital. EMS helped him place the resident in a regular seat and he secured her with a seatbelt. Driver Staff A said the wheelchairs are secured in the van with 4 tie-down straps, 2 in the front and 2 in the back. He said the problem was that there were no tie-down straps available to secure the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 105522 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105522 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lehigh Acres Healthcare & Rehab Center 1550 Lee Boulevard Lehigh Acres, FL 33936 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)