Inspection·December 7, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure adequate supervision and assistive devices to prevent multiple falls, including falls with injury for 1 (Resident #2) of 3 residents reviewed for falls. The findings included: Review of the clinical record for Resident #2 revealed an admission to the facility of 6/28/23 with a most recent re-admission date of 10/17/23. Diagnoses included Dementia with other behavioral disturbances, Parkinsonism, and depression. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 3 out of 10 which indicated severe cognitive impairment. The care plan initiated on 6/30/23 showed Resident #2 was at risk for falls related to a history of multiple falls, unsteady balance, confusion, diagnosis of dementia with behaviors. The interventions included encourage and assist the resident to wear appropriate footwear such as nonskid socks, encourage and remind resident to use call bell and wait for staff assistance with transfers, toileting, ambulation, etc. date initiated 6/30/23. Nonslip surface to wheelchair as tolerated, date initiated 7/11/23, revised 12/6/23. Encourage the resident to use wheelchair positioning/safety devices anti roll backs initiated 7/27/23. Psych evaluation due to behaviors date initiated 11/03/23. Request medication review initiated 8/1/23 and again on 11/2/23. The care plan noted Resident #2 was uncooperative. On 12/6/23 at 12:30 p.m., Resident #2 was observed in a wheelchair. There was no nonskid cushion in the wheelchair. On 12/6/23 at 12:50 p.m., Resident #2 was observed in the dining room with his wife. Resident #2's wife said the resident did not have a cushion in his chair to stop him from slipping out of the chair. The wife said he had one at one time. (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 4 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 12/07/2023 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)