Cycle 1
Health 2025-05-22 · Fire 2025-05-22
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fort Myers, FL
Larsen Health Center
3-star overall rating with 3-star inspections with $32,139 in total fines with 3 recent health deficiencies
13880 Shell Point Plaza, Fort Myers, FL
(239) 466-1111
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
180
Certified beds
Average residents
133
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
The Christian And Missionary Alliance
Operator or chain grouping
Approved since
1997-08-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.85
Registered nurse staffing
LPN hours / resident day
0.68
Licensed practical nurse staffing
Aide hours / resident day
4.29
Nurse aide staffing
Weekend hours
6.28
Weekend nurse staffing
RN turnover
49%
Annual RN turnover
Total nurse turnover
48%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.1
0.3 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.2
0.8 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
97.8%
1.1 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.7% |
99.2%
1.5 pts worse
|
95.5%
2.2 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.1% |
2.6%
1.5 pts worse
|
3.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
3.7%
1.8 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 2.0% |
5.9%
3.9 pts better
|
5.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.6% |
15.7%
2.9 pts worse
|
19.6%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 17.5% |
9.8%
7.7 pts worse
|
16.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 22.1% |
11.7%
10.4 pts worse
|
16.3%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.7% |
9.8%
3.9 pts worse
|
14.9%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.3% |
0.4%
1.9 pts worse
|
1.0%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
0.8%
2.6 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.8% |
12.5%
0.7 pts better
|
19.8%
8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
5.1%
0.5 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
94.3%
5.1 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.0% |
9.3%
5.7 pts worse
|
12.0%
3 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.9% |
1.5%
1.4 pts worse
|
1.6%
1.3 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.7% |
94.7%
5 pts worse
|
79.7%
10 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.5% |
26.2%
5.3 pts worse
|
23.9%
7.6 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-16 · Fire 2023-03-16
8 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Cycle 3
Health 2021-07-01 · Fire 2021-07-01
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-03-16
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-04-16
F · Potential for more than minimal harm
2023-03-16
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-04-16
F · Potential for more than minimal harm
2023-03-16
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-04-16
F · Potential for more than minimal harm
2023-03-16
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-04-16
F · Potential for more than minimal harm
2023-03-16
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-04-16
F · Potential for more than minimal harm
2023-03-16
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2023-04-16
E · Potential for more than minimal harm
2023-03-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-04-16
E · Potential for more than minimal harm
2023-03-16
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2023-04-16
D · Potential for more than minimal harm
2023-03-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-16
F · Potential for more than minimal harm
2021-07-01
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2021-07-30
F · Potential for more than minimal harm
2021-07-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-07-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-22
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-22
D · Potential for more than minimal harm
2025-05-22
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2025-06-22
D · Potential for more than minimal harm
2025-05-22
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-06-22
G · Actual harm
2025-01-16
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-02-14
G · Actual harm
2023-03-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-16
E · Potential for more than minimal harm
2023-03-16
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2023-04-16
E · Potential for more than minimal harm
2023-03-16
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-04-16
E · Potential for more than minimal harm
2023-03-16
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2023-04-16
D · Potential for more than minimal harm
2023-03-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-16
D · Potential for more than minimal harm
2023-03-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-16
D · Potential for more than minimal harm
2023-03-16
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2023-04-16
D · Potential for more than minimal harm
2021-07-01
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2021-09-24
D · Potential for more than minimal harm
2021-07-01
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2021-09-24
D · Potential for more than minimal harm
2021-07-01
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-09-24
D · Potential for more than minimal harm
2021-07-01
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2021-09-27
D · Potential for more than minimal harm
2021-07-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-09-27
Penalties and ownership
What sits behind the stars
$32,139
2025-01-16
Fine
Fine · fine $32,139
Fine
Ownership
The Christian And Missionary Alliance
5% Or Greater Indirect Ownership Interest · Organization
Anderson, Wanda
Corporate Director · Individual
Baldes, Ken
Corporate Director · Individual
Burdzy, Jon
Corporate Director · Individual
Candelore, Michele
Operational/Managerial Control · Individual
Candelore, Michele
Corporate Director · Individual
Cass, Paul
Corporate Director · Individual
Christman, Chanley
Corporate Director · Individual
Davidson, John
Corporate Director · Individual
Dewitt, Charles
Corporate Director · Individual
Duss, Donna
Corporate Director · Individual
Dys, Jeremy
Corporate Director · Individual
Flanders, Tom
Corporate Director · Individual
Glenn, James
Corporate Director · Individual
Hibbard, Jay
Corporate Director · Individual
Huisman, Henry
Operational/Managerial Control · Individual
Ofarrell, Mark
Corporate Director · Individual
Rainey, Lewis
Operational/Managerial Control · Individual
Rainey, Lewis
Corporate Officer · Individual
Scales, Michael
Corporate Director · Individual
Schappell, Martin
Operational/Managerial Control · Individual
Schappell, Martin
Corporate Officer · Individual
Vassar, Tasha
Corporate Director · Individual
White, Archie
Corporate Director · Individual
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#2
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5-star overall rating with 5-star inspections
#3
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1-star overall rating with 1-star inspections with abuse icon flag with $78,430 in total fines with 15 recent health deficiencies
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