Lehigh Acres Healthcare & Rehab Center
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
front of the wheelchair. He said after the incident, the facility placed him back in training. Driver Staff A said
he knew what he was doing, he just didn't have the right equipment. He confirmed he received training and did not properly secure Resident #900's wheelchair.On 8/22/25 at 10:30 a.m., in an interview the Administrator said the facility investigated the incident. He said tie-down straps were available to secure the wheelchairs. The driver did not use them properly, he failed to follow the process in his training. The transport drivers are responsible to make sure the tie-down straps are there and in proper working order.Review of the Compliance Training Attendance Log revealed Driver Staff A attended a 2 hour training
on 8/14/25. The training consisted of a lecture, a written posttest, general compliance, and job specific.On 8/22/25 at 2:05 p.m., observation of the van with Driver Staff B revealed 7 removable tie-down straps in the wheelchair tracks. Driver Staff B demonstrated how to move the tie-down straps and place them where needed to ensure the wheelchairs are properly secured.Review of the facility provided investigation revealed Driver Staff A provided a written statement which noted on 8/18/25 at about 10:00 a.m., he was leaving a red light turned green. He heard the resident yell and saw the resident' s wheelchair had gone backwards on the floor. He pulled over, released the tie-downs and safety belt and slid the chair out from under her. 911 was called but the resident refused to go to the hospital.The Assistant Director of Nursing documented in a statement Resident #900 said she was in the van and the chair was all strap down and so
we thought. The resident said the driver went to take off when a light changed and she went backward. The resident said a police officer stopped to help and they called EMS. She refused to go to the hospital. They picked her up and placed her in a regular seat in the van, then drove back to the facility.The investigation noted Resident #900 sustained a large skin tear to the left shin, a medium size laceration to the right lower leg, a skin tear to the right elbow and a small skin tear to the right 3rd toe.The facility determined the root cause of the incident was the third strap was missing and was not available, Maintenance to order and not available yet.On 8/22/25 at 3:09 p.m., during a second interview, Driver Staff A said on 8/18/25, there were tie-down straps available to secure Resident #900's wheelchair. He verified the tie-down straps can be moved and placed where needed to secure the wheelchairs. When asked the reason for not moving tie-down straps to ensure Resident #900's wheelchair was properly secured, he said, This would have been
an option. He said the straps were really hard to move, fidgety and hard to get back in the track.
Event ID:
Facility ID:
If continuation sheet
LEHIGH ACRES HEALTHCARE & REHAB CENTER in LEHIGH ACRES, FL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LEHIGH ACRES, FL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from LEHIGH ACRES HEALTHCARE & REHAB CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.