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
Chain footprint
2 facilities
Chain averages 4 overall / 3 health / 5 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.85
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
4.29
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
6.81
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.52
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
6.28
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
1.51
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
2.02
CMS adjusted RN staffing hours
Adjusted total hours
7.46
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
49%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
961
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.67
Composite VBP score used to determine payment impact.
Payment multiplier
1.0167
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.83% · Performance 22.28% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
10
Baseline 4.60% · Performance 4.81% · Measure score 10 · Achievement 10 · Improvement 0
Total nurse turnover
5.65
Baseline 30.54% · Performance 40.59% · Measure score 5.65 · Achievement 5.65 · Improvement 0
Adjusted total nurse staffing
9.02
Baseline 5.09 hours · Performance 5.64 hours · Measure score 9.02 · Achievement 9.02 · Improvement 7.53
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.59% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 617 · Observed rate 8.91% · Lower 95% interval 8.37% |
| Discharge to community | 62.37% |
50.57%
11.8 pts better
|
Better than the National Rate · Eligible stays 609 · Observed rate 60.1% · Lower 95% interval 58.33% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 91.42% |
95.27%
3.8 pts worse
|
Numerator 341 · Denominator 373 |
| Falls with major injury | 0.54% |
0.77%
0.2 pts better
|
Numerator 2 · Denominator 373 |
| Discharge self-care score | 43.73% |
53.69%
10 pts worse
|
Numerator 129 · Denominator 295 |
| Discharge mobility score | 33.22% |
50.94%
17.7 pts worse
|
Numerator 98 · Denominator 295 |
| Pressure ulcers or injuries, new or worsened | 1.07% |
2.29%
1.2 pts better
|
Numerator 4 · Denominator 373 · Adjusted rate 1.62% |
| Healthcare-associated infections requiring hospitalization | 4.81% |
7.12%
2.3 pts better
|
Better than the National Rate · Eligible stays 378 · Observed rate 2.91% · Lower 95% interval 3.17% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 60 |
| Staff flu vaccination coverage | 32.64% |
42%
9.4 pts worse
|
Numerator 126 · Denominator 386 |
| Discharge function score | 48.14% |
56.45%
8.3 pts worse
|
Numerator 142 · Denominator 295 |
| Transfer of health information to provider | 97.06% |
95.95%
1.1 pts better
|
Numerator 66 · Denominator 68 |
| Transfer of health information to patient | 97.37% |
96.28%
1.1 pts better
|
Numerator 222 · Denominator 228 |
| Resident COVID-19 vaccinations up to date | 1.95% |
25.2%
23.2 pts worse
|
Numerator 4 · Denominator 205 |
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 · Adjusted 2.4 · Observed 2.0 · Expected 1.6 · Used in QM five-star |
| 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 · Adjusted 2.0 · Observed 1.8 · Expected 1.5 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 98.3% · Q3 99.1% · Q4 98.2% · 4Q avg 98.9% |
| 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 · 4Q avg 97.7% |
| 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 · Q1 4.2% · Q2 4.2% · Q3 3.5% · Q4 4.5% · 4Q avg 4.1% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 1.9% · Q3 2.0% · Q4 4.1% · 4Q avg 1.9% |
| 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 · Q1 4.8% · Q2 0.0% · Q3 0.0% · Q4 3.1% · 4Q avg 2.0% |
| 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 · Q1 18.6% · Q2 20.5% · Q3 16.9% · Q4 18.2% · 4Q avg 18.6% |
| 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 · Q1 11.5% · Q2 18.6% · Q3 21.8% · Q4 18.8% · 4Q avg 17.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · Q1 24.4% · Q2 22.5% · Q3 16.9% · Q4 23.9% · 4Q avg 22.1% · Used in QM five-star |
| 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 · Q1 16.9% · Q2 13.3% · Q3 9.4% · Q4 14.8% · 4Q avg 13.7% · Used in QM five-star |
| 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 · Q1 2.8% · Q2 1.5% · Q3 2.3% · Q4 2.6% · 4Q avg 2.3% · Used in QM five-star |
| 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 · Q1 5.2% · Q2 4.3% · Q3 2.8% · Q4 0.9% · 4Q avg 3.4% · Used in QM five-star |
| 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 · Q1 11.9% · Q2 8.0% · Q3 13.7% · Q4 13.9% · 4Q avg 11.8% |
| 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 · Q1 7.0% · Q2 3.5% · Q3 4.9% · Q4 2.7% · 4Q avg 4.6% · Used in QM five-star |
| 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 · Q1 99.0% · Q2 99.5% · Q3 99.4% · Q4 100.0% · 4Q avg 99.4% |
| 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 · Adjusted 15.0% · Observed 13.0% · Expected 9.7% · Used in QM five-star |
| 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 · Q1 0.8% · Q2 2.7% · Q3 4.1% · Q4 5.1% · 4Q avg 2.9% · Used in QM five-star |
| 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 · 4Q avg 89.7% |
| 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 · Adjusted 31.5% · Observed 22.9% · Expected 17.3% · Used in QM five-star |
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
Nearby options
Other facilities in reach
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Lodge At Cypress Cove, The
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5-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
#2
Healthpark Care Center
Fort Myers, FL
5-star overall rating with 5-star inspections
#3
Ambassador Healthcare At College Park
Fort Myers, FL
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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