Larsen Health Center
13880 Shell Point Plaza, Fort Myers, FL 33908 · Non profit - Corporation · 180 certified beds · (239) 466-1111 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (5/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $32,139 in federal fines (most recent 2025-01-16)
- its payroll-based staffing score sits well above its independent inspection score
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 16.9% | 8.7% | 15.4% | typical |
| Long-stay residents who lose too much weight | 2.9% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.7% | 0.3% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.1% | 0.7% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 1.9% | 4.6% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.5% | 2.5% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 17.5% | 9.5% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 18.1% | 14.4% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 97.7% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.8% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 14.5% | 10.5% | 21.2% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 20.9% | 8.6% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 3.7% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 89.7% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 27.6% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 14.0% | 9.1% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.22 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.04 | 1.15 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
62.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 609 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 46.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 248 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.32 therapist hours per resident per day in 2026Q1 — more than 53% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 62.4%CMS range 58.3–65.4 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.6%CMS range 8.4–13.0 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 46.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 42.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 35.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 94.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 97.9% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 96.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.7% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 4.8%CMS range 3.2–6.6 | 7.1% | Oct 2023–Sep 2024 | better than U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.79 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 180 beds and averages 152.8 residents a day — about 85% occupied, or roughly 27 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.60 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.42 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.56 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 5.21 hrs/resident/day on weekends vs 5.76 on weekdays — 10% thinner on weekends. RN hours go from 1.55 to 1.08 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
17 citations, most serious first. The 12 most serious are shown; the remaining 5 are one tap away and print in full.
- Actual harm · G2025-01-16 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility's policies and procedures, and staff interviews, the facility failed to protect residents' rights to be free from abuse by failing to honor the residents' right to refuse care for 1 (Resident #999) of 3 sampled residents when the resident displayed agitated and aggressive behaviors during care. The findings included: The facility policy Abuse Policy and Procedure Manual with a review date of 3/24/23 noted, Each person served has the right to be free from abuse and mistreatment . Some examples, rough handling a resident. Prevention. Appropriate supervision of staff to maintain the mission of caring for, serving and satisfying all residents is provided .Signs and Symptoms Dementia residents in distress may exhibit the following: Aggressiveness, agitation, yelling out, delusions, wandering etc. Be aware of risk factors (age, cognitive and or physician limitations, etc.) . Listen to residents . If they say stop, stop! The facility Employee Agreements signed upon hire…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2023-03-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy and procedures, record review and staff interviews, the facility failed to provide adequate supervision and implement necessary interventions to prevent avoidable accidents for 1 (Resident #143) of 4 residents reviewed who were identified as being at risk for falls and sustained multiple falls at the facility, and a fracture requiring a transfer to a higher level of care. The findings included: The facility policy Fall Management Program origination 3/8/17 (revised 11/22) documented, The Falls Management Program is an interdisciplinary quality improvement program that provides resident fall processes and outcomes. The program utilizes a systemic approach to assessment, individualized intervention and monitoring that will result in injury reduction and minimizing fall risk to our residents . The IDT [interdisciplinary team] will complete a thorough investigation as well as a root cause analysis of all falls by completing a Post Fall Review form. The care plan, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, facility policy review, resident and staff interviews, the facility failed to provide care and services in accordance with the resident's individualized care plan to minimize the risk of avoidable accidents for 1 (Resident #1) of 3 dependent residents reviewed for transfers.The findings included:Review of the facility Transfer of Resident Using Support Devices policy (last revised on 11/2017) noted The Therapy Department will screen residents and determine a level of assistance. This determination will be incorporated into the plan of care for the resident and communicated to the staff by the means of the care plan.Review of the facility Care Plan- Interdisciplinary Resident policy (last revised on 1/2025) noted A comprehensive care plan will be developed for each resident that include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. All personnel who provide care to the resident, including private duty, shall have access to and be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-22 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility staff, resident and resident's representative interviews, the facility failed to develop and implement a comprehensive care plan to meet the needs of 1 (Resident #123) of 2 residents reviewed with a cardiac pacemaker (implanted device to treat irregular heart rhythm). The findings included: Review of the Resident #123's clinical record revealed a hospital surgical history of a cardiac pacemaker. The facility's physician admission progress note dated 4/9/25 revealed Resident #123 had a past medical history of a pacemaker. On 4/21/25, the Advanced Practice Registered Nurse (APRN) documented in a progress note that Resident #89's surgical history included a pacemaker. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #123 scored 12 on the Brief Interview for Mental Status (BIMS) indicative of moderate cognitive impairment. The diagnoses listed on the MDS did not include the presence of a cardiac pacemaker. Review of the care plan for Resident #123 noted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-22 · tag F0825 — isolatedProvide or get specialized rehabilitative services as required for a resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, the facility failed to follow physician's orders and provided skilled therapy services for 1 (Residents #89) of 4 residents reviewed for following physician's orders. The findings included: Review of the clinical record for Resident #89 revealed an admission date of 3/31/25. Diagnoses included debility and sarcopenia (age related loss of muscle mass and strength). Review of the Minimum Data Set (MDS) admission assessment with a target date of 4/6/25 revealed Resident #89 scored 14 on the Brief Interview for Mental Status (BIMS), indicative of intact cognition. Resident #89 required supervision or touching assistance to stand from sitting in a chair or on the side of the bed. The resident required supervision or touching assistance to walk 10 feet and partial to moderate assistance to walk at least 50 feet and make two turns. Review of the care plan initiated on 4/1/25 revealed Resident #89 was at risk for falls due to recent fall with pelvic fracture, Alzheimer's, weakness, low endurance, and decreased mobility as a result of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-22 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records review, observation and staff interviews the facility failed to accurately document physician ordered treatments for 2 (Residents #82 and Resident #93) of 2 resident's reviewed with feeding tubes. The findings included: Review of the facility's Charting and Documentation Policy revealed the facility, is committed to ensuring that all services provided to the resident, progress towards the care plan goals . is documented in the resident's medical record . The following information is to be documented in the resident medical record: . Treatments or services performed . Documentation in the medical record will be objective . complete, and accurate . documentation of procedures and treatments will include care-specific details, including: . The date and time the procedure/treatment was provided; The name and title of the individual(s) who provided the care . The signature and title of the individual documenting . Review of the facility's Gastrostomy Enteral Nutrition Via Gravity policy (last revised 9/2022) revealed states under the steps in the procedure section to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-03-16 · tag F0680 — patternEnsure the activities program is directed by a qualified professional.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy and staff interviews, the facility failed to ensure the activities program was directed by a qualified professional who is a qualified therapeutic recreation specialist or an activity professional. This has the potential to affect all current residents residing in the facility. The findings included: The facility policy, Activity Programs - Staffing (revised June 2018) documented, Our activity programs are staffed with personnel who have appropriate training and experience to meet the needs and interests of each resident. Our activity programs are under the direct supervision of a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who is licensed or registered, if applicable by the state in which practicing. On 3/15/23 at 3:14 p.m., Activity Aide Staff H said the facility did not have an Activity Director to oversee the activity programs. Staff H said there were five activity aides to cover six floors of the facility. She said they are each assigned a floor and there are two units on each…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-03-16 · tag F0700 — patternTry 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, records review and facility policy review the facility failed to review the risks and benefits of bed rails with the resident/representative or attempt alternative interventions prior to bed rail installation for 5 residents, (#28, #97, #110, #143 and #554) of 5 residents reviewed for bed rails. The findings included: Review of facility policy titled, Grab Bars, revised 1/2023 stated, This program will promote resident mobility with the highest quality of care while maintaining resident safety. These guidelines are to ensure the safe use of grab bars as restraints unless necessary to treat a resident's medical symptoms. 1. Clinical records review for Resident #97 documented an admission date to the facility of11/14/22. A Grab bar data collection form was completed on 11/15/22 at 2:36 p.m. An order was entered on 11/15/22 at 2:34 p.m. for patient to have bilateral grab bars. A verbal consent for side rail device was signed by the Health Care Surrogate on11/15/22. On 3/13/23 at 945 a.m., observed bilateral grab bar / side rails elevated on both sides…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-03-16 · tag F0909 — failed to maintain a comfortable temperature — patternRegularly 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and staff interview, the facility failed to conduct regular inspection of all bed frames, mattresses, and grab bars, as part of a regular maintenance program to ensure they remain safe, in good operating condition and to identify areas of possible entrapment for residents with grab bars. This had the potential to cause serious injury to the residents. The findings included: On 3/14/23 random observations on all six floors of the facility revealed multiple residents with grab bars on the beds in the raised position. Review of the facility's list of residents with grab bars revealed 117 residents had grab bars installed on their bed. On 3/16/23 at 10:44 a.m., in an interview the Maintenance Manager said the grab bars are on the beds prior to a resident's admission. He said we order them from the manufacturer and we put them on, that is all we do. We do not assess the grab bars or beds for areas of entrapment. The Maintenance Manager said he receives a work ticket from the staff requesting grab bars and they are placed on the beds. He said the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-16 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy and procedures, record review and staff interviews, the facility failed to have documentation of a thorough investigation related to alleged violations, including injuries of unknown origin for 2 (Resident #143 and #140) of 3 sampled residents reviewed for accidents. The findings included: 1. The facility policy Fall Management Program origination 3/8/17 (revised 11/22) documented, The Falls Management Program is an interdisciplinary quality improvement program that provides resident fall processes and outcomes. The program utilizes a systemic approach to assessment, individualized intervention and monitoring that will result in injury reduction and minimizing fall risk to our residents. An incident report will be completed for every resident fall within 24 hours. The interdisciplinary team (IDT) will complete a thorough investigation as well as a root cause analysis of all falls by completing the Post Fall Review Form. Review of the clinical record revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-16 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, review of the facility's policy and procedure, resident and staff interviews, the facility failed to provide care and services in accordance to professional standards of practice to meet the needs of 2 (Resident #148, and #67) of 5 sampled residents reviewed for skin condition. The findings included: 1. Clinical record review revealed Resident #148 was admitted to the facility on [DATE]. Diagnoses included fracture of the right femur. Resident #148 was non-weight bearing on the right leg. The physician's orders dated 1/27/23 included to apply thigh high TED hose (compression stockings) every morning before rising and remove at bedtime. On shower days, staff was to apply the TED hose after the shower and remove at bedtime. The admission Minimum data set (MDS) assessment dated [DATE] revealed resident #148 was cognitively intact. The resident required limited physical assistance of one person for dressing (including donning/removing a prosthesis or TED hose), and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-16 · tag F0687 — failed to care for feet properly — isolatedProvide appropriate foot care.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, review of facility's policy and procedure, resident representative and staff interviews, the facility failed to assist with necessary podiatry follow up appointments for 1 (Resident #81) of 5 sampled residents reviewed. The findings included: The facility's policy and procedure for care of the fingernails and toenails reviewed February 2018 noted the purpose included to keep nails trimmed, and to prevent infections. The general guidelines specified unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairment; stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease. Review of the clinical record for Resident #81 revealed an admission date of 11/18/21. Diagnoses included generalized muscle weakness, dementia, and high blood pressure. Resident #81 resided in the Memory Care Unit of the facility. The Quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 2/20/23 noted the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 5 citations
- Potential for harm · D2021-07-01 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, interview, and observation, the facility failed to develop and implement an activity program consistent with resident preferences choices for 1 (Resident #73) of 28 residents sampled for activities. The findings include: Resident's #73 medical record revealed an admission date of 5/7/21, with the following active diagnoses of Diabetes, the comprehensive assessment notes vision: Cataracts, Glaucoma, or Macular Degeneration; the resident wear glasses. On 6/29/21 at 9:41 a.m., during Resident #73 observation, the resident was sitting in the chair, completing his breakfast, and stated the meals were ok. The television was on. The resident was asked about activities. He said, I don't think I can leave this room; my wife comes and visits. When asked about the picture in his room of him and his wife, the resident said, I can't see the picture of me and my wife. When asked about audio books, the resident said, How does that work? Review of the Activity Care Plan revealed, Resident's length of stay is expected to be of short duration to complete rehabilitation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-07-01 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, review of facility policy and procedure, record review, and staff and resident interview, the facility failed to follow Physician orders and Therapy recommendations to provide and document daily restorative nursing care ordered for 1 (Resident #3) of 1 resident observed for restorative care. The finding included: The facility policy titled, Restorative Nursing Services, revised 09/2020, states, The purpose is to provide services that will increase or maintain functional performance in activities of daily living, diminish the risk of psychological and physiological complications of inactivity and enhance the resident's dignity and quality of life in the skilled car setting. Procedure #3 states, After receiving and reviewing the forms, the Restorative Nurse will enter the new information into the AOD [Answers on Demand] charting system. The facility policy titled Point of Care Documentation, revised 09/2020, states, Minimum daily charting by nursing assistants on every shift for every resident shall include the following a. ADLS [Activities of Daily Living], b.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-07-01 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, policy and record review, the facility failed to ensure proper weight management for a high-risk resident by not properly assessment and following facility policy for weight monitoring. The finding include: A review of facility policy and procedure on Resident Weight Management, last revision on 8/20, records: 1. Each resident's weight is obtained upon admission or readmission within 24 hours, by the nursing staff. 2. Each admission/re-admission is then weighed weekly for 4 weeks by designated nursing staff 6. Residents who are identified at risk for weight loss/gain will be reviewed with appropriate intervention and a plan of care at the weekly Risk Management committee meeting. On 6/28/21 at 12:12 p.m., Resident #480 was observed sitting in her chair at the bedside. Resident appeared significantly underweight and cachectic (extreme weight loss and muscle wasting). Her face was thin and her collar bones, wrist bone and hip bone were markedly visible even through her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-07-01 · tag F0725 — failed to have enough nursing staff — isolatedProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, and staff interview, the facility failed to provide sufficient and consistent nursing staff to meet the needs of 6 residents (Resident #25, #34, #60, # 65, #111, and #482) of 6 residents sampled. The failure to maintain sufficient and consistent staffing, resulted in the inability of nursing staff to respond to call lights and provide nursing related services to the residents in order to maintain the highest practicable physical, mental, and psychosocial well-being. The findings included: On 6/28/21 at 11:48 a.m. Observation of Resident #482's room revealed the call light was illuminated from 11:48 a.m. to 12:13 p.m. when a Certified Nursing Assistant (CNA) Staff N from another hall came to answer the light, she then turned off the light and left the room, she came back 4 minutes later (12:17 p.m.). On 6/28/21 at 12:17 p.m., in an interview, CNA Staff N said she did not know how to transfer the resident so she could not get her up. CNA Staff N said she would just get her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-07-01 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, interview, and policy review, the facility failed to ensure residents, receiving continuous positive airway pressure (CPaP) oxygen therapy per a machine, implemented preventive measures to lessen the development of a respiratory infection and the transmission of communicable diseases for 1 (Residents #73) of 2 residents sampled using a CPaP machine. The findings include: Initial observation on 6/28/21, at 10:45 a.m., revealed Resident #73 had a CPaP machine, with the mask not bagged. (photo evidence) On 6/28/21 at 10:45 a.m., during an interview Resident #73 said, I use the machine sometimes during the night when I am short of breath. The nurses clean it and put water in it when I tell them too. The CPaP mask was uncovered. On 6/30/21 at 9:15 a.m., observation of Resident #73's room revealed the CPaP mask was not bagged. On 6/30/21 at 9:21 a.m., in an interview, Director of Nursing said, The CPaP machine belongs to the resident, and Yes the mask portion should be in a bag when not used. On 6/30/21 at 3:45 p.m., observation of Resident #73's room…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$32,139 in federal fines across 1 penalty.
- $32,139 — penalty dated 2025-01-16
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to THE CHRISTIAN AND MISSIONARY ALLIANCE — 2 facilities. Here is how its ratings compare with the chain’s average across all its homes:
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 4.5 | -0.5 vs chain |
| Health inspection | 3 of 5 | 3.0 | ≈ chain avg |
| Staffing | 5 of 5 | 5.0 | ≈ chain avg |
| Quality measures | 2 of 5 | 3.5 | -1.5 vs chain |
The other 1 home this chain runs (chain average 4.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| THE CHRISTIAN AND MISSIONARY ALLIANCE | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 03/23/1967 |
| ANDERSON, WANDA | Individual | CORPORATE DIRECTOR | — | since 01/01/2008 |
| BALDES, KEN | Individual | CORPORATE DIRECTOR | — | since 01/01/2001 |
| BURDZY, JON | Individual | CORPORATE DIRECTOR | — | since 01/01/2020 |
| CANDELORE, MICHELE | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/31/2025 |
| CASS, PAUL | Individual | CORPORATE DIRECTOR | — | since 01/01/2002 |
| CHRISTMAN, CHANLEY | Individual | CORPORATE DIRECTOR | — | since 05/01/2011 |
| DAVIDSON, JOHN | Individual | CORPORATE DIRECTOR | — | since 11/01/1995 |
| DEWITT, CHARLES | Individual | CORPORATE DIRECTOR | — | since 01/01/1990 |
| DUSS, DONNA | Individual | CORPORATE DIRECTOR | — | since 01/01/1994 |
| DYS, JEREMY | Individual | CORPORATE DIRECTOR | — | since 01/01/2020 |
| FLANDERS, TOM | Individual | CORPORATE DIRECTOR | — | since 01/01/2022 |
| GLENN, JAMES | Individual | CORPORATE DIRECTOR | — | since 01/01/1991 |
| HIBBARD, JAY | Individual | CORPORATE DIRECTOR | — | since 10/01/2009 |
| OFARRELL, MARK | Individual | CORPORATE DIRECTOR | — | since 01/01/1994 |
| SCALES, MICHAEL | Individual | CORPORATE DIRECTOR | — | since 11/01/2002 |
| VASSAR, TASHA | Individual | CORPORATE DIRECTOR | — | since 06/04/2017 |
| WHITE, ARCHIE | Individual | CORPORATE DIRECTOR | — | since 01/01/2008 |
| RAINEY, LEWIS | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/06/2020 |
| SCHAPPELL, MARTIN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 03/21/2016 |
| HUISMAN, HENRY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/31/2025 |
| AEGIS THERAPIES, INC. | Organization | ADP OF THE SNF | — | since 10/01/2021 |
| POLARIS HEALTH LLC | Organization | ADP OF THE SNF | — | since 03/25/2025 |
| STAFFMD, LLC | Organization | ADP OF THE SNF | — | since 01/07/2025 |
CMS files one row per role, so the 30 rows in the source record cover these 24 parties — each is shown once here with every role it holds. Nothing is omitted.
4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $229K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in FL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105966. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-22, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.