Inspection visit
Inspection
15 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 15 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0578
Level of Harm - Minimal harm
or potential for actual harm
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.
Based on record review, review of facility policy, and staff interviews the facility failed to ensure accurate
advance directives were in place for 1 (Resident #19) of 6 residents reviewed.
Residents Affected - Few
The findings included:
Review of the facility's clinical insight titled, Advanced Care Planning: Code Status, updated September
2021 stated, Advanced care panning is a phrase defined by CMS (Center for Medicare and Medicaid
Services) . as a process used to identify and update the patient's preferences regarding care and treatment
at a future time, including a situation in which the patient subsequently lacks capacity to do so. It is a
comprehensive phrase that includes both wishes that are established by physician orders and those
established by advanced directives. Code status is always established by a physician order . Nursing role at
the time of admission: . Review / provide the correct state specific forms with the patient and/or family
member, paying special attention to the patient's cognitive status, responsible party, and/or POA (Power of
Attorney) documentation . Social services role within the first five (5) days of admission: . Social Service
should ensure that code status has been established and is appropriately communicated within both the
medical record and the electronic medical record .
On 3/23/22 at 8:05 a.m., reviewed medical record for Resident #19 including electronic and paper record.
The paper record contained a handwritten note that read, Full Code as of 8/20/21 per daughter . See note.
Nurse notified and is now full code on PCC (Point Click Care) as well.
Further review showed Resident #19 was admitted to facility on 12/20/2019. The medical record contained
and incapacity statement signed and dated on 12/24/19 by the psychiatrist. No additional healthcare proxy
or POA (Power of Attorney) was present in the clinical records for resident #19.
On 3/23/22 at 9:55 a.m., in an interview Licensed Practical Nurse (LPN) Staff E said she was caring for
Resident #19. LPN Staff E said advance directives documentation should be in the medical record. After
looking at the electronic and paper medical record, LPN Staff E said should could not find documentation of
a POA or health care proxy for Resident #19.
On 3/23/22 at 11:10 a.m., in an interview the Social Services Director (SSD) Staff G said she reviewed the
medical record and could not find documentation of a health care proxy or POA for Resident #19. She said,
We should have gotten a healthcare proxy or POA as soon as she was deemed incapacitated.
On 3/23/22 at 12:00 p.m., Interviewed facility administrator who confirmed POA, and Healthcare proxy were
not in resident #19 record. The Administrator said staff should not be obtaining consents
(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 17
Event ID:
106020
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
106020
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/24/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eagleridge Health and Rehabilitation Center
13881 Eagle Ridge Drive
Fort Myers, FL 33912
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)
F 0578
from people without having the healthcare proxy or POA as part of the clinical record.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106020
If continuation sheet
Page 2 of 17
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
106020
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/24/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eagleridge Health and Rehabilitation Center
13881 Eagle Ridge Drive
Fort Myers, FL 33912
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)
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
2. On 3/21/22 review of the clinical record for Resident #58 revealed an admission MDS assessment with a
target date of 2/11/22. The assessment noted Resident #58 received dialysis While a resident and while not
a resident at the facility.
Residents Affected - Few
On 3/21/22 at 9:57 a.m., in an interview Resident #58's spouse said her husband has not received dialysis
prior to or during his stay at the facility.
On 3/22/22 at 12:01 p.m., in an interview MDS Coordinator staff Z confirmed Resident #58's admission's
MDS was inaccurately coded for dialysis.
Based on clinical record review, review of facility policy, staff and resident interviews the facility failed to
ensure the Minimum Data Sets (MDS) assessment accurately reflected the medical status of 2 (Residents
#57 and #58) of 5 residents reviewed for dialysis care. Inaccurate MDS assessments can result in a
resident not receiving appropriate health care.
The findings included:
The facility's guideline titled, Clinical Records Resource Manual with an original date of 3/2022 read,
Accuracy of assessment means that the appropriate, qualified health professionals correctly document the
resident's medical status, functional, and psychosocial problems and identify resident strengths to maintain
or improve medical status, functional abilities, and psychosocial status using the appropriate Resident
Assessment Instrument (RAI) .
1. On 3/22/22 review of the clinical record for Resident #57 revealed an admission MDS with a target date
of 2/10/22. The MDS noted Resident #57 received dialysis (Procedure to remove waste products and
excess fluid from the blood when the kidneys stop working properly) while not a resident and while a
resident at the facility.
On 3/22/22 at 9:43 a.m., in an interview Resident #57 said she was not and has never been on dialysis.
On 3/22/22 at 12:04 p.m., in an interview MDS coordinator Staff Z verified the admission MDS assessment
noted Resident #57 received dialysis. MDS coordinator Staff Z said the assessment was inaccurate and
dialysis must have been marked in error.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106020
If continuation sheet
Page 3 of 17
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
106020
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/24/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eagleridge Health and Rehabilitation Center
13881 Eagle Ridge Drive
Fort Myers, FL 33912
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)
F 0679
Provide activities to meet all resident's needs.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, resident and staff interview the facility failed to provide an ongoing activity
program that supports resident's preferences for 1 (resident #510) of 2 residents reviewed for activities.
Residents Affected - Few
The findings included:
Review of the clinical record revealed Resident #510 was admitted to the facility on [DATE].
The Recreation/Activity Evaluation form with an effective date of 3/14/22 noted Resident #510's current
leisure interests included music (oldies), news programs, variety of movies, religious involvement (catholic),
general talking, conversing. The form also noted the Resident pursues recreation with assistance and
needed assistance with wheelchair.
Review of the care plan initiated on 3/14/22 showed Resident #510's goal was to actively engage in
one-to-one activity visits at least three times a week. Visits would include but not limited to current events,
sensory stimulation, and companionship. The care plan did not include interventions for religious
involvement.
On 3/21/22 at 2:55 p.m., in an interview Resident #510 said there were no activities on the weekend. He
said it would be nice to do something, but no one has informed him or invited him to activities. Resident
#510 said no one gave him an activity calendar, he just sits in the room. An activity calendar was not
observed in Resident #510's room during interview.
On 3/23/22 at 9:25 a.m., in an interview the Activity Director said activities such as church services,
meditation, and one-to-one visits are offered on weekends. He said activity participation is documented on
a flow sheet. The Activity Director said he could not find documentation of activity participation for Resident
#510 since admission to the facility. He said he did not have a flow sheet verifying the activity care plan was
implemented, including the one-to-one visits for current events, sensory stimulation, and companionship.
On 3/23/22 at 10:12 a.m., in a follow up interview Resident #510 said he spends his time sitting in his room.
He said he would like to attend church services and listen to the radio. He said the activity staff do not come
and talk with him or invite him to activities.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106020
If continuation sheet
Page 4 of 17
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
106020
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/24/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eagleridge Health and Rehabilitation Center
13881 Eagle Ridge Drive
Fort Myers, FL 33912
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)
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, review of facility's policy and procedure, and staff interviews, the facility failed to
ensure 1 (Resident #410) of 2 sampled residents at risk for development of pressure ulcers received
necessary services to prevent the worsening and development of pressure ulcers. Resident #410's
pressure ulcer significantly deteriorated, and the resident developed additional pressure ulcers.
Residents Affected - Few
The findings included:
Review of the Facility's Skin Management Guidelines with an original date of 2/2022 revealed, Purpose: To
describe the process steps required for identification of patients at risk for the development of skin
alterations, identify, prevention techniques and interventions to assist with the management of pressure
injuries and skin alterations . Body audits are completed: By the licensed nurse daily for patients with
pressure injuries and documented on the eTAR (Electronic Treatment Administration Record); new findings
are documented in a progress note . Skin preventions strategies that can be implemented upon admission
for any patient may include . Repositioning and offloading pressure . Pressure reducing support surfaces .
On 3/22/22 record review revealed Resident #410 was admitted to the facility on [DATE] with diagnoses
including Parkinson's disease, chronic pain, and pressure ulcer to the left buttock.
The admission Minimum Data Set (MDS) assessment with a target date of 3/14/22 revealed the Resident
required extensive physical assistance of two persons for bed mobility (How the resident moves to and from
lying position, turns side to side, and positions body while in bed or alternate sleep furniture). The MDS
noted Resident #410 was admitted with one stage 2 pressure ulcer (Partial thickness loss of skin
presenting as a shallow open ulcer).
The Admission/re-admission Evaluation form dated 3/8/22 noted Resident had redness to the coccyx (bone
structure at the base of the spine) and a left buttock stage 2 pressure ulcer.
Review of the Braden Scale (Tool used for predicting pressure ulcer risk) dated 3/8/22 and 3/15/22 showed
Resident #410 was at high risk for developing pressure ulcers. Resident #410 was bedfast (confined to
bed); had very limited ability to change and control body position; skin was constantly moist by perspiration,
urine; dampness detected every time patient is moved or turned.
The Braden Scale also showed friction and shear was a problem. The Resident required moderate to
maximum assistance in moving. Complete lifting without sliding against sheets was impossible; frequently
slides down in bed or chair, requiring frequent repositioning with maximum assistance.
Review of Resident #410's care plan showed on 3/8/22 the facility initiated a care plan noting the Resident
was at risk for alteration in skin integrity related to impaired mobility, incontinence, and peripheral arterial
disease. Preventive measures included to apply barrier cream to the peri area and buttocks as needed,
elevate heels as able and tolerated, encourage to reposition as needed, observe skin condition with care
daily and report abnormalities and pressure redistributing device on bed.
The care plan did not address Resident #410's existing stage 2 pressure ulcer to the buttocks or specific
measures to promote healing and prevent the worsening of the pressure ulcer.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106020
If continuation sheet
Page 5 of 17
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
106020
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/24/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eagleridge Health and Rehabilitation Center
13881 Eagle Ridge Drive
Fort Myers, FL 33912
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)
F 0686
The Treatment Administration Record (TAR) lacked documentation of daily body audits per the facility's
policy.
Level of Harm - Actual harm
Residents Affected - Few
Review of the wound care practitioner's progress notes dated 3/10/22 revealed Resident #410 had a stage
2 pressure ulcer to the superior left buttock measuring 2.17 centimeters (cm) in length, 3.66 cm in width
and 0.1 cm in depth. The practitioner documented Specialty low air loss mattress ordered.
The clinical record lacked documentation the facility obtained and applied the low air loss mattress
(specialty mattress to help prevent and heal pressure ulcers by eliminating high pressure points) to the bed
as ordered.
On 3/17/22 the wound care practitioner documented the presence of a new stage 2 pressure ulcer to the
left lateral malleolus (ankle). She documented, Low air loss mattress was ordered 3/10/22. I viewed order in
chart. I reordered today . [Resident #410] is . basically immobile. Complains of pain L (left) lateral malleolus
and buttocks . It's concerning that this patient is developing a new pressure ulcer, however it is attributable
to her immobility .
The left upper buttock wound now measured 2.3 cm (length) by 3.8 cm (width) by 0.1 cm (depth).
The newly identified left lateral ankle wound measured 0.4 cm (length) by 0.6 cm (width) by 0.1 cm (depth).
On 3/21/22 at 9:54 a.m., 3/22/22 at 11:09 a.m., and 3/23/22 at 9:59 a.m., Resident #410 was observed in
bed. The low air loss mattress was not observed on the bed.
On 3/24/22 at 8:21 a.m., observation of Resident #410's wounds with the wound care Advanced Practice
Registered Nurse (APRN) revealed the Stage 2 pressure ulcer to the left upper buttock had worsened. The
APRN said the wound was now unstageable due to the presence of slough (dead tissue) and DTI (Deep
tissue injury) next to it. The APRN said she will consider the whole area as one unstageable wound that
measured 5.2 cm (length) by 5.9 cm (width). The APRN was not able to measure the depth of the wound
due to the presence of dead tissue.
During the wound care observation, Resident #410 complained of pain to the right lateral leg.
Observation of the right lateral leg revealed a new open area which the wound care APRN said was a
stage 2 pressure ulcer measuring 2.0 cm (length) by 2.0 cm (width).
Resident #410 now had a total of 3 pressure ulcers injuries.
On 3/24/22 at 6:08 p.m., in an interview the Director of Nursing (DON) said there was a breakdown in
communication. The DON said there was a lack of nursing interventions to prevent new pressure ulcers and
minimize the deterioration of the pressure ulcer Resident #410 was admitted with. The DON acknowledged
the failure to obtain and apply the low air loss mattress to the bed contributed to the worsening of Resident
#410's existing pressure ulcer and the development of two new stage 2 pressure ulcers.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106020
If continuation sheet
Page 6 of 17
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
106020
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/24/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eagleridge Health and Rehabilitation Center
13881 Eagle Ridge Drive
Fort Myers, FL 33912
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)
F 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, review of facility's policy and procedure, and staff interview, the facility failed to
provide appropriate interventions to prevent the worsening of contracture for 1 (Resident #19) of 2 residents
reviewed with a limitation of range of motion (ROM). This has the potential to cause pain and worsening of
the contracture.
The findings included:
A review of the facility's Restorative Nursing Guideline (New Procedure 08/2019) stated, Restorative
nursing care includes nursing interventions that help to maintain the patient's highest level of function and
prevent unnecessary decline in function . Patients may enter a restorative nursing program in several ways
including after discharge from a skilled physical, occupational or speech rehabilitation program.
During observations on 3/21/22 at 11:29 a.m., 3/22/22 at 10:45 a.m., 3/23/22 at 9:35 a.m., Resident #19
was observed with bilateral hand contractures (Flexed joint that cannot be straightened actively or
passively). The Resident was not wearing a splinting device to the hands. Resident #19 was not able to
respond to attempt to interview.
Review of the care plan created on 11/19/20 revealed Resident #19 had a contracture of the left hand third,
fourth and fifth finger. The goal was for the resident to remain free of complications related to the
contracture of the left hand. The intervention dated 1/5/22 was for the left palm protector to be worn at all
times as tolerated.
Review of the [NAME] (Contains important resident's needs and current status) showed a left palm
protector to be worn at all times as tolerated.
On 3/23/22 at 9:47 a.m., in an interview Patient Care Assistant (PCA) Staff HH said she has worked at
facility for about two weeks caring for resident #19. PCA Staff HH said she has never seen Resident #19
with a hand guard or hand splint on since she has worked at the facility.
On 3/23/22 at 12:59 p.m., in an interview Certified Nursing Assistant (CNA) Staff C said she has worked at
the facility for the past three weeks and has taken care of Resident #19 several times. She said she has
never seen Resident #19 with a hand brace of palm protector.
On 3/23/22 at 1:01 p.m., CNA Staff B was observed in the dining room with resident #19. CNA Staff B said
she has never seen Resident #19 with a hand splint or hand guard. CNA Staff B asked, Should I put a
washcloth in her hand?
On 3/23/22 at 1:04 p.m., in an interview Minimum Data Set (MDS) coordinator Staff Z reviewed resident
#19 care plan and confirmed on 1/5/22 the care plan was updated to reflect the left-hand contracture and
the application of a left palm protector to be worn at all times as tolerated. MDS coordinator Staff Z also
confirmed the left palm protector was on the [NAME] and should be in use.
On 3/23/22 at 3:36 p.m., in an interview Licensed Practical Nurse (LPN) Staff A said Resident #19 used to
have a palm guard but I haven't seen it in a while.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106020
If continuation sheet
Page 7 of 17
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
106020
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/24/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eagleridge Health and Rehabilitation Center
13881 Eagle Ridge Drive
Fort Myers, FL 33912
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)
F 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 3/23/22 at 3:42 p.m., in an interview Occupational Therapist (OT) Staff MM said Resident #19 was
evaluated on 12/10/21 then discharged from therapy with a palm guard in place. OT Staff MM said the OT
department completed a communication sheet for nursing to follow any recommendations.
On 3/23/22 at 3:49 p.m., the Director of Rehab Staff RR provided the survey team with a communication
form dated 1/6/22 specifying to apply a palm guard to the left upper extremity as tolerated 7 times a week.
The Director of Rehab Staff R confirmed communication form copy goes to the Director of Nursing (DON)
or Unit Manager for nursing follow-up.
On 3/24/22 at 9:10 a.m., in an interview OT Staff NN said if the palm guard is not used consistently, it would
be at risk of her hand contractures getting worse. OT Staff NN said, We want to keep her hands in the best
functional position as possible.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106020
If continuation sheet
Page 8 of 17
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
106020
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/24/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eagleridge Health and Rehabilitation Center
13881 Eagle Ridge Drive
Fort Myers, FL 33912
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)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, record review, policy and procedure review and staff interview, the facility failed to
ensure 1 (Resident #463) of 1 sampled resident receiving oxygen had a written physician's order for
oxygen therapy.
Residents Affected - Few
The findings included:
Review of the policy and procedure titled, Oxygen Administration with an original date of 6/2021 revealed,
Purpose: To describe method for delivering oxygen in order to treat hypoxia (low oxygen level), improve
tissue oxygenation, and reduce shortness of breath with activity . Procedure: 1. Verify Physician's order .
On 3/21/22 review of the clinical record revealed Resident #463 had diagnoses including chronic
obstructive pulmonary disease with acute exacerbation. The clinical record did not list a physician's order
for oxygen for Resident #463.
On 3/21/22 10:37 a. m., Resident #463 observed in bed receiving Oxygen at two liters via nasal cannula
(device used to deliver supplemental oxygen through the nostrils).
Random observations on 3/21/22, 3/22/22 , 3/23/22, and 3/24/22 showed Resident #463 receiving oxygen
at two liters via nasal cannula.
On 3/24/22 at 7:56 a.m., in an interview the Administrator verified the lack of a physician's order for oxygen
for Resident #463.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106020
If continuation sheet
Page 9 of 17
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
106020
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/24/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eagleridge Health and Rehabilitation Center
13881 Eagle Ridge Drive
Fort Myers, FL 33912
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)
F 0698
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, resident and staff interviews, the facility failed to ensure documentation of effective
coordination of care and adequate monitoring for complications and appropriate interventions for 2
(Resident #79 and #56) of 3 sampled dialysis residents reviewed.
Residents Affected - Some
The findings included:
1. On 3/21/22 at 9:09 a.m., in an interview Resident #79 said her dialysis center discharged her. She said
she has not had dialysis (filtering of wastes and water from the blood) for a week now. She wanted to
remain on dialysis and had made the facility aware of her wish.
On 3/22/22 at 4:40 p.m., in an interview Resident #79's spouse said the dialysis center had canceled
services for his wife. He wanted his wife to continue with dialysis and Resident #79 is also in agreement.
On 3/22/22 at 5:01 p.m., in an interview the Social Service Director said she is aware Resident #79 wants
to continue dialysis.
On 3/22/22 at 5:28 p.m., in an interview The North Unit Manager Staff L, said the dialysis center was
checking Resident #79 labs (laboratory tests), weight and administered medications. Since dialysis
discharge, the facility does not have a physician order to monitor labs and changes for Resident #79.
Resident #79 has a dialysis port with no clear directions on how to maintain and care for the device. Staff L,
RN said that Resident #79 told her she wants to pursue dialysis.
On 3/23/22 clinical record review revealed Resident #79 was admitted to the facility on [DATE]. Diagnoses
included but were not limited to End Stage Renal Failure. Resident #79 had been receiving hemodialysis
three times a week at an outpatient dialysis center.
The clinical record contained a 30-day discharge notice dated 2/18/22 from the dialysis center to Resident
#79 for disruptive behavior at the dialysis center.
Resident #79's last documented dialysis treatment was dated 3/15/2022.
The clinical record lacked documentation of a plan to monitor Resident #79's signs and symptoms of renal
disease requiring additional interventions.
On 3/23/22 at 8:17 a.m., in an interview, the APRN (Advanced Practice Registered Nurse) Staff M, said she
did not know Resident #79 had been discharged from dialysis. She said, in such instances, orders to check
for labs and changes should be put in place and order to send the resident to the emergency room for
treatment when the resident is symptomatic.
On 3/23/22 at 8:26 a.m., in an interview, the Director of Nursing (DON) said she spoke with the Medical
Director when the dialysis center issued the 30-day discharge notice to the resident. She said the Medical
Director gave her a verbal order to find alternate placement for dialysis and just observe for decline and
treat symptoms. The DON said she failed to transcribe the verbal orders to Resident #79's medical record.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106020
If continuation sheet
Page 10 of 17
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
106020
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/24/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eagleridge Health and Rehabilitation Center
13881 Eagle Ridge Drive
Fort Myers, FL 33912
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)
F 0698
Level of Harm - Minimal harm
or potential for actual harm
On 3/23/22 at 01:15 p.m., in an interview, the Medical Director said he was aware Resident #79's dialysis
was discontinued on 3/15/22. He said Resident #79 was discharged from several dialysis centers due to
her behavior. He had conversations with the Resident #79, her spouse, and the facility. He's involved
psychiatric services. The Medical Director said he will write orders to obtain labs and if the resident
becomes symptomatic to send her to the hospital.
Residents Affected - Some
On 3/24/22 at 11:04 a.m., Review of labs obtained on 3/23/22 showed Creatinine was 12.1 (HH=Critical
high); Potassium 7.3 (HH=critical high); Anion gap 21 (H=high).
On 3/24/22 at 11:19 a.m., in an interview the Registered Dietitian said Resident #79 was sent to the
emergency room on 3/24/22 at 4:00 a.m., per physician's orders to be dialyzed due to the significantly
abnormal labs.
2. Clinical record review revealed Resident #56 was admitted to the facility on [DATE]. The admission
Minimum Data Set (MDS) assessment with a target date of 2/9/22 showed Resident #56 received dialysis
while at the facility.
Resident #56 was discharged to an acute care hospital on 3/5/22 and returned to the facility on 3/8/22.
The discharge orders from the hospital (fax date of 3/8/22) included calcium acetate (Phoslo) 667
milligrams (mg) capsules, take 1,334 mg by mouth 3 times daily with meals.
The Facility's physician orders included hemodialysis every Tuesday, Thursday, and Saturday with a 6:00
a.m. pickup time; Calcium Acetate 667 mg, give 2 capsules by mouth three times a day for phosphate
binder.
The order did not specify to administer with meals or food.
Review of the MAR (Medication Administration Record) for 3/2022 showed as of 3/9/22 the calcium acetate
was scheduled to be administered daily at 9:00 a.m., 1:00 p.m., and 5:00 p.m.
On 3/21/22 at 10:11 a.m., in an interview Resident #56 said he goes to the dialysis center on Tuesdays,
Thursdays, and Saturdays. On dialysis days, he leaves the facility at approximately 6:30 a.m. and returns at
approximately 11:30 a.m. Resident #56 said the facility provides him a meal which he eats at the dialysis
center. He said the nurses administer the calcium acetate (phosphorus binder) to him upon return from the
dialysis center.
Review of the MAR for 3/2022 showed documentation the nurse administered the calcium acetate at 9:00
a.m., on 3/10/22 (Thursday), 3/12/22 (Saturday) and 3/15/22 (Tuesday).
On 3/17/22 (Thursday), 3/19/22 (Saturday) and 3/22/22 (Tuesday) the nurse entered 3 (Out of center) on
the MAR.
On 3/23/22 at 10:03 a.m., in an interview the Registered Dietitian (RD) said Resident #56 is on a renal diet
due to dialysis. She said if a phosphorus binder (medication used to prevent the body from absorbing the
phosphorus from the food you eat) is ordered, it should be given with food, no earlier than half hour before
the meal or half hour after meal.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106020
If continuation sheet
Page 11 of 17
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
106020
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/24/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eagleridge Health and Rehabilitation Center
13881 Eagle Ridge Drive
Fort Myers, FL 33912
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)
F 0698
Level of Harm - Minimal harm
or potential for actual harm
On 2/23/22 at 12:20 p.m., in an interview the Interim Administrator verified the calcium acetate for Resident
#56 should be given with food. He also verified the Resident leaves the facility on dialysis days at 6:00 a.m.,
and did not take the phosphorus binder with him.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106020
If continuation sheet
Page 12 of 17
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
106020
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/24/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eagleridge Health and Rehabilitation Center
13881 Eagle Ridge Drive
Fort Myers, FL 33912
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)
F 0726
Level of Harm - Minimal harm
or potential for actual harm
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.
Based on observation, interview and record review, the facility failed to ensure 1(Agency nurse staff X) of 2
agency nurses observed had the appropriate skill sets to provide services in a safe and timely manner.
Residents Affected - Few
The findings included:
On 3/22/22 at 11:22 a.m., Registered Nurse (RN) Agency Staff X was observed preparing morning
medications at the medication cart. The Assistant Director of Nursing (ADON) was standing next to Staff X
at the medication cart. The ADON said she was helping Staff X because RN Staff X was an agency nurse
and had not worked at the facility before.
The ADON said Staff X was learning the computer and medication cart. The ADON confirmed the
medications being prepared by Staff X were morning medications that were overdue.
On 3/22/22 at 11:30 a.m., Staff X was observed preparing medications to administer to Resident #511. The
ADON was observed instructing Staff X how to sign off the medications in the computer system.
On 3/22/22 at 12:09 p.m., Staff X administered morning medications to Resident #511. RN Staff X did not
sign off the medications she administered into the computer system. The ADON was not present to assist
her.
On 3/22/22 at 12:24 p.m., RN Staff X left the unit. The ADON said she and the RN Unit Manager Staff L
would continue giving the morning medications that were overdue.
On 3/22/22 at 1:18 p.m., Unit Manager Staff L was observed preparing to administer the same medications
RN Staff X administered to Resident #511 on 3/22/22 at 12:09 p.m. Upon surveyor's intervention Staff L did
not administer the medications. Unit Manager Staff L said she did not know RN Staff X had already
administered the medications to Resident #511 since they were not signed off in the computer system.
On 3/22/22 at 2:14 p.m., in an interview the Director of Nursing (DON) said there was no training process
for agency nurses. The DON said, If they have never been to the facility before, she gives them a short
run-down so she is not there for 3 hours.
On 3/23/22 at 8:44 a.m., in a telephone interview RN Staff X said she did not know the computer system
and had not given medications in a long time. She said she did not receive any training before her first day
at the facility and it was a hard job to do.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106020
If continuation sheet
Page 13 of 17
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
106020
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/24/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eagleridge Health and Rehabilitation Center
13881 Eagle Ridge Drive
Fort Myers, FL 33912
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)
F 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review, the facility failed to ensure a medication error rate less
than 5%. Three nurses and 33 of opportunities were observed. Twenty medication errors were identified
resulting in a 60.60% medication error rate.
Residents Affected - Some
The findings included:
On 3/22/22 at 11:22 a.m., Registered Nurse (RN) Staff X was observed administering seven medications
for Resident #110, including one capsule of Gabapentin 400 milligrams (mg), one tablet of Famotidine
Tablet 20 mg, one tablet of Skelaxin 800 mg.
Upon reconciliation of the observation with the physician's orders for 3/3022, it was revealed an order for
Gabapentin Capsule 400 mg, give 1200 mg by mouth three times a day for neuropathy. The medication was
scheduled for 9:00 a.m., 1:00 p.m., and 5:00 p.m. The 9:00 a.m. dose was not administered until 11:22
a.m., two hours and 22 minutes past the scheduled time. RN Staff X also administered Gabapentin 400 mg
instead of Gabapentin 1200 milligrams.
The physician's order for the Famotidine Tablet 20 mg was to administer one tablet by mouth two times a
day for gastric esophageal reflux disease (GERD). The medication was scheduled for 9:00 a.m., and 5:00
p.m.
The physician's order for Skelaxin Tablet 800 mg specified to give one tablet by mouth two times a day for
muscle spasm. The medication was scheduled to be given at 9:00 a.m., and 5:00 p.m.
The physician's orders for Resident #110 also included to administer Lopid 600 mg by mouth two times a
day for cholesterol (scheduled for 9:00 a.m., and 5:00 p.m.), and Lovenox (anticoagulant) 400 mg
subcutaneously (Scheduled for 9:00 a.m. and 9:00 p.m.). RN Staff X did not administer the Lopid or the
Lovenox as ordered.
On 3/22/22 at approximately 11:30 a.m., RN Staff X verified the morning dose of Gabapentin, famotidine
and Skelaxin were administered more than two hours past the scheduled time.
2. On 3/22/22 at 12:09 p.m. Staff X was observed administering eight different medications to Resident
#511 including one tablet of Xarelto tablet 15 mg, Namenda 10 mg and Levetiracetam 500 mg, Cetirizine
10 mg, calcium with vitamin D 3 250-125 mg, Jardiance 10 mg, Omeprazole 40 mg, and vitamin B 6 100
mg.
The physician's orders for the Xarelto were to give 15 mg by mouth twice daily with meals until 4/10/22. The
Xarelto was scheduled for 9:00 a.m. and 5:00 p.m.
The orders for Namenda were to administer 10 mg by mouth two times a day for cognition. The medication
was scheduled for 9:00 a.m. and 5:00 p.m.
The orders for Levetiracetam were to give 500 mg by mouth two times a day for seizures. The medication
was scheduled for 9:00 a.m. and 5:00 p.m.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106020
If continuation sheet
Page 14 of 17
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
106020
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/24/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eagleridge Health and Rehabilitation Center
13881 Eagle Ridge Drive
Fort Myers, FL 33912
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)
F 0759
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
On 3/22/22 at 12:24 p.m., RN Staff X verified the Xarelto, Namenda and Levetiracetam were administered
three hours past the scheduled time. RN Staff X did not sign off the medications for Resident #511 and left
the facility.
On 3/22/22 at 1:18 p.m., RN Unit Manager Staff L was observed preparing to administer eight different
medications to Resident #511, including one tablet of Xarelto tablet 15 mg, Namenda 10 mg, Levetiracetam
500 mg, Cetirizine 10 mg, calcium with vitamin D 3 250 mg/125, Jardiance 10 mg, Omeprazole 40 mg, and
vitamin B 6 100 mg.
Unit Manager RN Staff L crushed all the medications and added them to apple sauce and took them to
Resident #511's room. Upon surveyor's intervention, RN Staff L was prevented from administering the
same medications RN Staff X previously administered on 3/22/22 at 12:09 p.m. Unit Manager Staff L said
since RN Staff X did not sign off the medications, she didn't realize Resident #511 had already received the
medications she attempted to administer.
3. On 3/22/22 at 12:24 p.m., the ADON was observed administering Levemir Insulin 30 units to Resident
#35.
The physician's orders for the Levemir were to administer 30 units two times a day. The medication was
scheduled for 9:00 a.m. and 9:00 p.m. The 9:00 a.m. dose of Levemir was administered 3.5 hours past the
scheduled time.
On 3/22/22 at 12:33 p.m., in an interview the ADON verified the Levemir was administered late.
4. On 3/22/22 at 12:45 p.m., the ADON was observed to administer medications to Resident #56, including
one tablet of calcium acetate 667 mg, Hydralazine 50 mg, pantoprazole 40 mg, and Eliquis 5 mg.
The physician's orders for the calcium acetate 667 mg were to administer two capsules by mouth three
times a day. The ADON only administered one capsule of calcium acetate to Resident #56, more than three
hours past the scheduled time of 9:00 a.m.
The orders for Hydralazine were to administer 50 mg by mouth three times a day for hypertension. The
medication was scheduled for 9:00 a.m., 1:00 p.m., and 9:00 p.m.
The orders for Eliquis were to administer 5 mg by mouth twice a day. The medication was scheduled for
9:00 a.m., and 9:00 p.m.
The orders for pantoprazole were to administer 40 mg by mouth twice a day for indigestion. The medication
was scheduled to be given at 9:00 a.m., and 5:00 p.m.
On 3/22/22 at 12:44 p.m. the ADON verified the medications were administered more than three hours past
the scheduled time. She said Resident #56 usually gets his medications at lunch time since he goes to
dialysis.
On 3/22/22 at 2:14 p.m., the observed medication errors were discussed with the DON. She confirmed the
medication errors for Resident #110, #511, #56 and #35.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106020
If continuation sheet
Page 15 of 17
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
106020
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/24/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eagleridge Health and Rehabilitation Center
13881 Eagle Ridge Drive
Fort Myers, FL 33912
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)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
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.
Based on observation, review of facility policy and staff interviews, the facility failed to ensure proper
labeling of medications in 2 (South Hall, and North middle hall) of 4 medication carts observed. The facility
failed to ensure expired medications were not retained longer than the expiration date in 1 (South Unit) of 2
medication storage rooms observed. This has the potential for expired medications to be administered to
residents.
The findings included:
The facility policy Storage and Expiration Dating of Drugs, Biologicals, Syringes and Needles (revised
8/20/18) documented:
#3. The nursing Center should ensure that all drugs and biologicals: Have an expiration date on the label or
medication container .Have not been retained longer than recommended by manufacturer or supplier
guidelines.
#4. Once any drug or biological package is opened, the Nursing Center should follow the manufacturer
guidelines with respect to expiration dates for opened medications. Nursing Center staff should record the
date opened on the medication container when the medication has a shortened expiration date once
opened.
1. On 3/24/22 at 3:19 p.m., observation of the South Hall medication cart with Registered Nurse (RN) Staff
H showed an opened bottle of latanoprost 0.005% prescription eye drops. The pharmacy label specified to
discard the medication six weeks after opening. The bottle of eye drops wasn't labeled with the date it was
first opened, making it impossible to determine when to discard the medication.
Staff H confirmed the bottle of latanoprost 0.005% was not dated to indicate when the medication was
opened.
Photographic evidence obtained.
2. On 3/24/22 at 3:31 p.m., observation of the South Unit medication room's refrigerator with RN Staff H
showed eight prefilled syringes of Tuberculin PPD (purified protein derivative) testing solution with the
expiration date of 3/12/22. RN Staff H confirmed the eight syringes had expired and should have been
discarded.
The refrigerator also contained a box labeled acetycsteine [sic] injection 20% (medication used to help thin
and loosen mucus in the airways due to certain lung diseases) with an expiration date of 11/2/21. RN Staff
H verified the expiration date of 11/2/21 and said the medication should have been discarded.
3. On 3/24/22 at 3:56 p.m., observation of the North Unit middle hall medication cart with RN Staff T
revealed the following:
Two opened, undated vials of Lantus insulin were stored in the top drawer of the medication cart. The label
on the insulin boxes specified to discard 28 days after opening.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106020
If continuation sheet
Page 16 of 17
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
106020
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/24/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eagleridge Health and Rehabilitation Center
13881 Eagle Ridge Drive
Fort Myers, FL 33912
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)
F 0761
RN Staff T confirmed the insulin vials and boxes were not dated and should have been discarded.
Level of Harm - Minimal harm
or potential for actual harm
Two unlabeled clear plastic medication cups containing several pills were stored in the second drawer.
Four unlabeled clear medication cups containing several pills each were stored in the third drawer.
Residents Affected - Some
Five unlabeled clear medication cups containing several pills each were stored in the third drawer.
RN Staff T said she was getting ready to start administering medications to the residents, pre-poured
medications for several residents and placed them in the drawers.
RN Staff T confirmed there were a total of 11 unlabeled medication cups and said, I know I should not have
pre-poured the medications.
RN Staff T verified pre pouring medications in unlabeled cups has the potential to administer the wrong
medications to the residents.
On 3/24/22 at 5:50 p.m., in an interview the Assistant Director of Nursing said she said the nurses were
responsible to ensure medications were dated and not used past the expiration date.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106020
If continuation sheet
Page 17 of 17
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
15 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
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.
F679 - Activities
Provide activities to meet all resident's needs.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F688 - Mobility
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.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F726 - Nursing Services
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.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F761 - Labeling of Drugs and Biologicals
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.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
- 0004GeneralS&S Fpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0033GeneralS&S Fpotential for harm
Establish methods for sharing information.
- 0035GeneralS&S Fpotential for harm
Provide family notifications of emergency plan.
- 0324GeneralS&S Dpotential for harm
Provide properly protected cooking facilities.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
FAQ · About this visit
Common questions about this visit
What happened during the March 24, 2022 survey of EAGLERIDGE HEALTH AND REHABILITATION CENTER?
This was a inspection survey of EAGLERIDGE HEALTH AND REHABILITATION CENTER on March 24, 2022. The surveyor cited 15 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at EAGLERIDGE HEALTH AND REHABILITATION CENTER on March 24, 2022?
Yes, 15 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.