Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0622
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Not transfer or discharge a resident without an adequate reason; and must provide documentation and
convey specific information when a resident is transferred or discharged.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, resident representative and staff interviews, the facility failed to have documentation of an
appropriate facility initiated discharge for 1 (Resident #1) of 3 sampled residents not permitted to return to
the facility after a hospital stay.
The findings included:
On 7/9/24, review of the facility initiated discharges revealed on 5/25/24 Resident #1 was transferred to an
acute care hospital and had not returned to the facility.
Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses
included dementia and cognitive communication deficit.
On 5/25/24 at 1:29 p.m., a nursing progress note documented Resident #1 was found unconscious and
transferred to a local emergency room for evaluation and treatment.
Review of the hospital physician's progress note dated 5/25/24 revealed Resident #1 presented from the
skilled nursing facility with an episode of syncope. The resident was unable to provide history. The physician
documented the information was obtained from staff and medical records. Diagnoses listed included
dementia. Resident #1 was admitted to the hospital with diagnoses including severe dehydration.
The hospital Discharge summary dated [DATE] noted Resident #1 will benefit from going back to snf
[skilled nursing facility]. The discharge disposition was , SNF.
Review of the hospital care management progress note dated 5/27/24 at 12:19 p.m., revealed Resident #1
was unable to provide permission to contact the family and state preferences and post-acute plan of care
due to Dementia. The Case Manager placed a call to Resident #1's daughter and discussed discharge
order for return to Life Care Center of Estero. The daughter agreed but requested to speak with the
attending physician to discuss her concerns for a safe discharge and to request cardiology to see the
resident before leaving the hospital. The discharge plan was to return to Life Care Center of Estero.
The patient's goals included, dementia, daughter's goals return to SNF with possible transition to LTC [Long
Term Care]. Return to SNF referral sent .
On 5/28/24 at 10:52 a.m., the hospital Case Manager documented receiving a call from the facility
(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 7
Event ID:
106057
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
106057
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/09/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Life Care Center of Estero
3850 Williams Road
Estero, FL 33928
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 0622
informing the case manager Resident #1, Was no longer accepted back at facility.
Level of Harm - Minimal harm
or potential for actual harm
The Case Manager documented receiving a call from the resident's daughter and her spouse, they
expressed confusion over facility change in decision. The Case Manager offered to have paperwork faxed
to other facilities to assist with placement. The daughter reported they were looking at Assisted Living
Facilities.
Residents Affected - Few
On 7/9/24 at 2:07 p.m., in an interview the facility's admission and Business/Development Director said the
facility communicates electronically with the hospital through an online referral system once a resident is
ready to be discharged .
The Director of Business Development provided the communication notes from the online referral system
which she said were for Resident #1.
On 5/27/24 at 3:33 p.m., the hospital documented asking if the facility had a bed today. The communication
note documented the resident had a discharge order.
On 5/27/24 at 4:01 p.m., and on 5/28/24 at 10:32 a.m., the facility documented on the online referral
system, Yes willing to accept patient.
On 5/28/24 at 10:40 a.m., the facility documented on the online referral system, No, unable to accept
patient. Under Reason the facility documented, Care Needs Exceed Current capacity.
On 7/9/24 upon request of the facility provided a Nursing Home Transfer and Discharge Notice dated
5/25/24 noting Resident #1 was transferred to a local hospital as his needs could not be met at the facility.
The Nursing Home to Hospital Transfer Form dated 5/25/24 noted the reason for transfer was loss of
consciousness (syncope).
The facility did not provide documentation that a Nursing Home Transfer and Discharge Notice was
provided to Resident #1 or his representative on 5/28/24 when the facility did not permit Resident #1 to
return to the facility upon discharge from the hospital.
On 7/9/24 at 4:15 p.m., in an interview the admission and Business/Development Director said there was
no additional documentation justifying the decision not to accept Resident #1 back after his hospital stay.
On 7/9/24 at 4:47 p.m., in a telephone interview Resident #1's daughter said the hospital called and
informed her that the facility would not accept her father back. She said no one at the facility called her to
explain the decision not to take her father back.
On 7/10/24, after the survey, the facility Administrator emailed a Witness Interview/Statement Form dated
7/10/24 for an incident date of 5/27/24 in which Unit Manager Registered Nurse Staff I documented, On
5/27/24 the unit received a call from [Resident #1's daughter] stating she was blaming us for her father's
hospital visit as he was dehydrated. She said if we couldn't be with him at all times to ensure his hydration
which we couldn't, then she wanted for him to go elsewhere. RN Staff B documented he notified the
admission department.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106057
If continuation sheet
Page 2 of 7
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
106057
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/09/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Life Care Center of Estero
3850 Williams Road
Estero, FL 33928
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 0622
Level of Harm - Minimal harm
or potential for actual harm
The clinical record lacked documentation of an appropriate basis for the facility initiated discharge for
Resident #1, including what care needs exceeded the facility's current capacity, or the facility's attempt to
meet the resident's needs.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106057
If continuation sheet
Page 3 of 7
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
106057
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/09/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Life Care Center of Estero
3850 Williams Road
Estero, FL 33928
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 0626
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds
bed-hold policy.
Based on record review, review of facility initiated discharges, resident representative and staff interviews
the facility failed to allow 1 (Resident #1) of 3 sampled residents to return and resume residence at the
facility after a transfer to the hospital.
The findings included:
Review of the clinical record showed Resident #1 was admitted the facility on 4/19/2024. Diagnoses
included dementia, and cognitive communication deficit.
The 5-Day Minimum Data Set (MDS) assessment with a target date of 5/10/2024 noted Resident #1
cognition was severely impaired with a Brief Interview for Mental Status (BIMS) score of 7.
Resident #1 required substantial/maximal assistance (helper does more than half the effort) for toileting
hygiene, shower/bathe, and footwear. He needed partial/moderate assistance (helper does less than half
the effort) for dressing. Resident #1's mobility needed partial/moderate assistance.
Resident #1 was occasionally incontinent of bladder and frequently incontinent of bowel.
The MDS noted the resident required setup or clean-up assistance with eating.
The care plan initiated on 4/26/24 noted Resident #1 has potential for fluid deficit related fair intake. The
resident had a history of diuretic use (helps the body get rid of extra fluid) and history of fluid restriction.
The interventions as of 4/26/24 included to honor fluid preferences; Staff to offer fluids in-between meals,
and water at bedside.
Review of the nursing progress notes revealed on 5/25/2024 at 1:29 p.m., Resident #1 was found
unconscious and was transferred to a local hospital, and subsequently admitted .
The facility completed an MDS on 5/25/24 for a, Discharge-return anticipated.
Review of the hospital emergency room physician progress note dated 5/25/24 noted Resident #1 came
from Life Care Center of Estero. Resident #1 was severely dehydrated. The resident was admitted for
further evaluation and treatment.
Review of the hospital care management progress note dated 5/27/24 at 12:19 p.m., revealed Resident #1
was unable to provide permission to contact the family and state preferences and post-acute plan of care
due to Dementia. The Case Manager placed a call to Resident #1's daughter and discussed discharge
order for return to Life Care Center of Estero. The daughter agreed but requested to speak with the
attending physician to discuss her concerns for a safe discharge and to request cardiology to see the
resident before leaving the hospital. The discharge plan was to return to Life Care Center of Estero.
On 5/28/24 at 10:52 a.m., the Case Manager documented receiving a call from the facility informing the
case manager Resident #1, Was no longer accepted back at facility.
The Case Manager documented receiving a call from the resident's daughter and her spouse, they
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106057
If continuation sheet
Page 4 of 7
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
106057
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/09/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Life Care Center of Estero
3850 Williams Road
Estero, FL 33928
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 0626
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
expressed confusion over facility change in decision. The Case Manager offered to have paperwork faxed
to other facilities to assist with placement. The daughter reported they were looking at Assisted Living
Facilities.
On 7/9/24 at 4:47 p.m., in a telephone interview Resident #1's daughter said the hospital called and
informed her that the facility would not accept her father back. She said no one at the facility called her to
explain the decision not to take her father back. She said her father remained at the hospital until 5/30/24
while she looked for a different facility. With the help of the hospital Case Manager, her father was placed in
an Assisted Living Memory Care Facility where she is now paying $6000.00 per month for his care. She
lives out of state, had to drive a full day to move him to the Assisted Living Facility, buy furniture, a
television set, and other items required by the Assisted Living Facility.
Resident #1's daughter said she called, left messages for the skilled nursing facility Administrator but no
one returned her calls.
On 7/9/24 at 2:07 p.m., in an interview the admission and Business/Development Director said the facility
communicates electronically with the hospital through an online referral system. once a resident is ready to
be discharged .
The Director of Business Development provided the communication notes from the online referral system
which she said were for Resident #1.
On 5/27/24 at 4:01 p.m., and on 5/28/24 at 10:32 a.m., the facility documented on the online referral
system, Yes willing to accept patient.
On 5/28/24 at 10:40 a.m., the facility documented on the online referral system, No, unable to accept
patient. Under Reason the facility documented, Care Needs Exceed Current capacity.
On 7/9/2024 at 3:36 p.m., in a telephone interview Registered Nurse (RN) Staff F said Resident #1's
daughter called and spoke with her about her father's return to the facility. The daughter wanted to make
sure he was drinking water. She informed the daughter she could not discuss her father's care at that time
as he was not an active resident.
On 7/9/24 at 4:15 p.m., in an interview the admission and Business/Development Director said there was
no additional documentation justifying the decision not to accept Resident #1 back after his hospital stay.
On 7/10/24 the facility Administrator emailed a Witness Interview/Statement Form dated 7/10/24 for an
incident date of 5/27/24 in which Unit Manager RN Staff I documented, On 5/27/24 the unit received a call
from [Resident #1's daughter] stating she was blaming us for her father's hospital visit as he was
dehydrated. She said if we couldn't be with him at all times to ensure his hydration which we couldn't, then
she wanted for him to go elsewhere. RN Staff B documented he notified the admission department.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106057
If continuation sheet
Page 5 of 7
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
106057
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/09/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Life Care Center of Estero
3850 Williams Road
Estero, FL 33928
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 0925
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations, review of facility's policy and procedure, review of records, residents and staff
interviews, the facility failed to maintain an effective pest control program for the kitchen and 7 (Residents
#2, #3, #4, #7, #8, #9 and #10) of 7 sampled residents who said they observed pest in their rooms or
throughout the facility.
Residents Affected - Some
The findings included:
Review of the facility's Pest Control policy reviewed and revised 6/4/24 revealed, The facility will maintain an
effective pest control program that provides frequent treatment of the environment for pests so that the
facility is free of pests and rodents . An effective pest control program is defined as measures to eradicate
and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitoes, flies, mice and rats).
On 7/9/24 at 8:27 a.m., in an interview Resident #2 said she had a roach in her room a few weeks ago. The
nurse sprayed some bug spray all over her floor. They found two big roaches dead on their back after that.
On 7/9/24 at 8:40 a.m., in an interview Residents #3 and #4 said they saw bugs every day in their rooms.
Resident #3 said he sees bugs along the base of the cabinet and kept a can of insect killer in his room.
On 7/9/24 at 8:43 a.m., in an interview Certified Nurse Assistant (CNA) Staff E said she sees flies all the
time. She sees them by the kitchen and sometimes in residents' rooms by the sink.
On 7/9/24 at 8:47 a.m., in an interview Licensed Practical Nurse (LPN) Staff G said she saw flies and
roaches on a weekly basis.
On 7/9/24 at 8:50 a.m., during a tour of the kitchen with the Director of Food Service, several small black
flying insects were observed hovering around the sink areas.
A white large bucket was observed under the back sink. When the bucket was moved, several small black
flying insects were seen hovering in the area. The bucket was coated with an oil substance with black
specks.
On 7/9/24 at 9:40 a.m., in an interview Housekeeping Assistant Staff D, said she saw roaches a lot. Staff D
said she catches the live ones with her mop sometimes when she is cleaning rooms.
On 7/9/24 at 10:30 a.m., during a group interview Residents #7 (Resident Council President), #2, #8, #9,
and #10 said they see bugs every day. They said the kitchen doors are left open 75% of the time. The doors
are connected to the dining room and they see roaches daily.
On 7/9/24 at 11:05 a.m., in an interview the Maintenance Director said if staff write a work order, he will go
spray for bugs. If it is excessive, he will call the bug company to come. The drains in the kitchen are to be
cleaned daily and then they pour a product to remove organic debris down the drains. There are 6 drains in
the kitchen. The bug company comes twice a month or as needed.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106057
If continuation sheet
Page 6 of 7
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
106057
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/09/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Life Care Center of Estero
3850 Williams Road
Estero, FL 33928
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 0925
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
On 7/9/24 at 11:45 a.m., in an interview the technician from the pest control company said he comes twice
a month to treat the facility. He reviews the logbook at each nurse station and treats the areas. Sometimes
staff pulls him aside and tells him other areas to treat. He said he treats the kitchen drains during each visit.
He sold the Director of Food Service a product to clean the drains when organic matter is present. He said
the flies are attracted to decay, dirty dishes, and other organic matter. They need to keep the drains clean to
prevent the flies to nest.
On 7/9/24 at 1:22 p.m., in an interview the Director of Food Service said the pest control technician told her
to use the [brand name] cleaning product daily in the mop water and then pour the mop water down the
drains. The staff mops three times a day with multiple pails of water. They make sure to pour mop water
down each drain.
On 7/9/24 at 3:45 p.m., in an interview the Director of Food Service Manager said they started roughly nine
months to a year ago to treat the drains with the cleaning formula. The pest control technician trained the
dietary staff were trained on how to use the [brand name] biologically enhanced cleaning formula. She said
staff signed the education form but did not have documentation of the education.
Review of the commercial services agreement dated 5/26/23 with the pest control company revealed under
service instructions, Fly control program: Current activity: Fruit flies/house flies. Includes twice per month fly
treatment of all drains in the kitchen area.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106057
If continuation sheet
Page 7 of 7
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
3 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.
F622 - Transfer and discharge-
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
F626 - Transfer and discharge-
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
F925 - Maintain an effective pest control program so that the facility is free of
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
FAQ · About this visit
Common questions about this visit
What happened during the July 9, 2024 survey of LIFE CARE CENTER OF ESTERO?
This was a inspection survey of LIFE CARE CENTER OF ESTERO on July 9, 2024. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LIFE CARE CENTER OF ESTERO on July 9, 2024?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific info..."
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.