Inspection visit
Inspection
16 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 16 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 3/14/23
at 1:50 p.m., Resident #140 was observed with a purplish-blue bruise under his right eye.
Residents Affected - Few
On 3/14/23 at 1:52 p.m. , Resident #140's wife said the bruise around her husband's right eye appeared
one-day several weeks ago. When she asked what happened they told her they did not know.
On 3/15/23 review of Resident #140's medical record revealed he was admitted on [DATE] with a diagnosis
of muscle weakness and Parkinson's disease. A nursing progress note dated 2/24/23 at 7:24 a.m. said at
7:15 a.m. they found a new small open area to Resident #140's right temple. They applied pressure to the
area and then left it open to the air. The cause of the open area was unknown, and the incident was
unwitnessed. Neuro checks were initiated. The daughter was notified, and staff would continue to monitor.
Resident #140's medical record revealed a fall care plan stating Resident #140 was at risk for falls due to
weakness, and poor safety awareness related to dementia diagnosis. Some of the approaches listed to
keep Resident #140 from falling were to keep the call light within reach, the bed in a low position, reduce
stimulus in the room at night, maintain adequate light when the resident was awake and keep personal
items within reach.
On 3/15/23 at 12:10 p.m., Certified Nursing Assistant (CNA) Staff K, she said when she came to work
several weeks ago, she found Resident #140 sitting in a chair. There was a large bruise around his right eye
and temple area but due to his dementia, he was unable to tell her what happened. She believed he hit his
head on something but did not know what caused the bruise on Resident #140's right temple and eye area.
She said no one from the administration interviewed her about the bruise on Resident #140's right temple
area.
On 3/16/23 at 10:57 a.m., the Director of Nursing (DON), she said Resident #140 was admitted to the
facility on [DATE]. She said due to Resident #140's increased confusion and safety concerns he was moved
to a secured unit. The DON reviewed Resident #140's medical record and confirmed the nurse wrote a
progress note on 2/23/23 at 7:43 a.m. which stated they found a new small open area to Resident #140
right temple. She said when an injury of unknown origin was found an incident report should be created
and a full investigation should be started to include resident and staff interviews to assist in determining
what could have caused the injury. The DON said after reviewing the 2/24/23 incident report, Resident #140
was found by Staff K in the living area with a bruise on his right temple. She said there was no
documentation they had interviewed any of the residents or staff to determine how the injury might have
occurred and/or put into place interventions to ensure it didn't happen again. She said the Nurse Manager
was responsible to conduct the investigation.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 15
Event ID:
105966
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105966
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Larsen Health Center
13880 Shell Point Plaza
Fort Myers, FL 33908
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 3/16/23 at 12:55 p.m., Nurse Manager Staff F and Clinical Coordinator Staff L, said they oversee the
memory care units. They said on 2/24/23 during the morning meeting they saw the incident report about a
bruise of unknown origin on Resident #140's right temple. After the morning meeting, they did an
assessment of the bruise of unknown origin on Resident #140's right temple. They said since it was not
bleeding, they did not have to get a treatment order. Staff F said they did not document their assessment of
the bruise on Resident #140's right temple area and did not investigate to determine how the bruise of
unknown origin might have occurred and/or put interventions in place to ensure it did not occur again.
On 3/16/23 at 4:26 p.m., the DON said after a full review of Resident #140's medical record, the incident
report, and the morning Stand Up meeting notes, she was unable to find the documentation they had
completed a full investigation into the bruise of unknown origin to Resident #140's right temple as required.
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 Resident #143 had an admission date of 1/20/23 and a readmission
date of 2/18/23 with diagnoses including Alzheimer's, dementia, left hip fracture, frequent falls, and aphasia
(loss of ability to express or understand speech).
The admission Minimum Data Set (MDS) (standardized assessment tool that measures health status in
nursing home residents) with an assessment reference date of 1/26/23 documented Resident #143
required limited assistance of one person with bed mobility, transfers, and ambulation.
The MDS noted a Brief Interview for Mental Status (assessment of a resident's cognitive function) was 99
indicating the resident was unable to complete the interview.
The facility fall assessment dated [DATE] determined the resident was a moderate risk for falls.
The facility initiated a care plan on 12/26/22 indicating Resident #143 was at risk for falls due to weakness,
low endurance and decreased mobility as a result of acute or chronic health conditions and aphasia.
The care plan interventions on 12/28/22 included to orient resident to room, call light, and need to call for,
and wait for assistance, maintain adequate lighting in resident's room, keep bed in lowest position possible,
attempt to keep resident as active in activities during the day as resident
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105966
If continuation sheet
Page 2 of 15
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105966
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Larsen Health Center
13880 Shell Point Plaza
Fort Myers, FL 33908
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
will allow.
Level of Harm - Minimal harm
or potential for actual harm
On 1/20/23 at 6:30 a.m., Resident #143 was found on the floor in her room and was unable to state what
she was doing at the time of the fall.
Residents Affected - Few
On 1/21/23 at 3:31 p.m., Unit Manager, Licensed Practical Nurse (LPN) Staff F completed the investigation
follow up and documented IDT (interdisciplinary team) meeting regarding found on floor next to bed.
Regular mattress in place. Work for grab bars placed. Intervention: Staff to ensure wheelchair to be placed
at bedside.
On 1/24/23 at 1:00 a.m., Resident #143 was found on the floor in her room. On 1/25/23 at 4:48 p.m., LPN
Staff F completed the investigation follow up and documented Visual reminder to use call bell for
assistance.
On 1/29/23 at 6:25 p.m., Resident #143 was found sitting on the floor. The incident report documented This
nurse was notified by neighboring resident family that she heard a big bang. Upon arrival resident was
observed sitting, guarding LLE (left lower extremity) and being in distress/teary. Three wheeled walker next
to her.
The nurse documented the resident reported pain pointing to the left knee. The nurse assessed Resident
#143 and documented the left lower extremity appeared shorter and rotated with substantial bruising. The
resident was sent to the local hospital emergency room where a left knee x-ray was obtained. The x-ray
report documented no acute fracture or dislocation. The resident was transferred back to the facility.
On 2/27/23 at 1:03 p.m., LPN Staff F completed the investigation follow up and documented, IDT meeting
regarding fall 1/29/23. Resident returned from ER (emergency room) continue B&B (bowel and bladder)
observation and set up B&B schedule for resident.
On 2/10/23 at 9:00 p.m., a facility incident report documented 2/9/23 resident complained of left hip pain,
primary nurse notified, some bruising and edema on left hip.
Resident #143 was sent to the local hospital emergency room where an x-ray confirmed acute left hip
fracture. The resident was admitted to the hospital and had a surgical repair of the left hip fracture on
2/12/23.
On 3/6/23 at 4:16 p.m., LPN Staff F completed the investigation follow up and documented, Left hip fx
(fracture). Provider notified supervisor to send to ER for left hip fx, pain management and ortho consult.
On 3/16/23 at 11:40 a.m., LPN Staff F said she completed the incident form on 1/29/23 at 6:25 p.m., when
Resident #143 was found on the floor. She said she did not find her. The Registered Nurse completed the
incident report but did not sign it and, I signed it after I reviewed it. The initial investigation process is the
manager or supervisor is notified. The process is to ensure we did contact the house supervisor. In this
situation, the supervisor sent her out.
Normally we review the incident and if it was a witnessed fall, we interview staff to see what they observed.
If the fall was unwitnessed we do not do interviews but we will now. The root cause of the fall on 1/29/23
was Resident #143 got up to go the bathroom because she does not get up unless she
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105966
If continuation sheet
Page 3 of 15
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105966
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Larsen Health Center
13880 Shell Point Plaza
Fort Myers, FL 33908
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
has to go to the bathroom. The resident is nonverbal and took herself to the bathroom. She was found next
to the bed with the walker so I figured she was going to the bathroom, it does not say that on the form. The
investigation as to why she fell was she was getting up to go to the bathroom it is what she always does.
LPN Staff F confirmed she did not have documentation of witness statements, and no documentation of an
interview with the family member who reported on 1/29/23 hearing a loud bang from the resident's room.
LPN Staff F said there was no documentation of additional falls between 1/29/23 and 2/10/23 when the left
hip fracture was identified. The LPN said, the resident was sent to the emergency room on 1/29/23 and
returned with no fracture, she was propelling herself in the wheelchair with no pain. On 2/9/23 she had pain
and we sent her for an x-ray, it showed a fracture, and she was sent to the Emergency Room. LPN Staff F
said I can't say for certain if Resident #143 was ambulating after the fall on 1/29/23 because there was no
documentation. I can't say for sure the left hip fracture was related to the fall on 1/29/23 because there was
no investigation.
On 3/15/23 at 1:38 p.m., the Administrator who is the Risk Manager said she did not investigate or file a
report to the required State Agency once the hospital identified an acute left hip fracture with Resident
#143, because we did not know what happened to her.
On 3/16/23 at 9:40 a.m., in an interview the Administrator said she did an informal investigation with staff
but had no documentation of an investigation for the acute left hip fracture. The Administrator confirmed
Resident #143 had multiple falls before the left hip fracture was identified on 2/10/23. The Administrator
confirmed the follow up and investigation section of the incident reports were completed several weeks
after the incident and did not show a complete investigation.
On 3/16/23 at 1:31 p.m., the Director of Nursing said they felt the fracture of the left hip was a result of the
fall on 1/29/23 but confirmed no investigation was completed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105966
If continuation sheet
Page 4 of 15
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105966
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Larsen Health Center
13880 Shell Point Plaza
Fort Myers, FL 33908
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0680
Ensure the activities program is directed by a qualified professional.
Level of Harm - Minimal harm
or potential for actual harm
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.
Residents Affected - Some
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 floor. Staff H said she bounced around a bit to
cover her assigned floor and assist with coverage on other floors.
On 3/15/23 at 4:21 p.m., the Administrator, said the Activity Director resigned on 10/21/22 and she had
tried to replace her. The Administrator said she was overseeing the activity department and was meeting
with the activity staff each week. The Administrator confirmed she did not have the credentials to oversee
the activity program.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105966
If continuation sheet
Page 5 of 15
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105966
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Larsen Health Center
13880 Shell Point Plaza
Fort Myers, FL 33908
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**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.
Residents Affected - Few
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 bathing.
Review of the Treatment Administration Record for 3/1/23 through 3/15/23 revealed documentation the TED
hose was applied daily at 6:00 a.m., and removed at 9:00 p.m., including on 3/13/23 and 3/14/23.
On 3/13/23 at 9:38 a.m., and 3:12 p.m., Resident #148 was observed sitting in a recliner. She was not
wearing the TED hose.
On 3/13/23 at 3:12 p.m., Resident #148 said she had never had the TED hose put on.
On 3/14/23 at 1:31 p.m., Resident #148 was observed in her room. She stated she was just returning from
the salon. Resident was not wearing the TED hose. She stated staff had never applied the TED hose to her
legs. She said no one asked if she wanted to wear them, and she had never refused to wear them.
On 3/15/23 at 2:51 p.m., in a telephone interview Licensed Practical Nurse (LPN) Staff X, stated she works
the night shift and took care of Resident #148. She said, I don't have any knowledge of her [Resident #148]
wearing the TED hose or refusing them. I do not recall putting them on her.
On 3/15/23 at 3:08 p.m., Certified Nursing Assistant (CNA), Staff S said Resident #148 required one
person assistance for dressing and transferring. She said, I didn't put the TED hose on her myself. I do not
recall seeing them on her.
On 3/15/23 at 3:28 p.m., LPN Staff O said she knew Resident #148 had an order to wear TED hose during
the day but she could not recall Resident #148 wearing them.
On 3/15/23 at 3:35 p.m., the Physical Therapist assigned to resident #148 stated she never saw the
resident with TED hose on.
On 3/16/23 at 3:41 p.m., Registered Nurse Staff Z stated she did not recall Resident #148 wearing
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105966
If continuation sheet
Page 6 of 15
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105966
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Larsen Health Center
13880 Shell Point Plaza
Fort Myers, FL 33908
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
TED hose, the resident may have refused on occasion. She said the flow sheet showing documentation of
the TED hose being put on and taken off may have been documented incorrectly, and she would have to
investigate it further.
2. The facility's policy and procedure titled Skin tear protocol with a policy revision date of 1/23 noted skin
tears will be treated immediately to expedite rapid healing. The procedure noted to write the order as
described. Cleanse with (brand name) wound cleanser . Apply silicone foam dressing. Change every seven
days and as needed. The protocol specified, in the presence of a skin tear, the procedure will be written as
an order and transcribed to the Treatment Administration Record. The Licensed Nurse will document the
procedure and the progress.
Review of the clinical record for Resident #67 revealed an admission date of 2/6/23.
The admission Minimum Data Set (MDS) assessment (tool to measure health status of nursing home
residents) with an assessment reference date of 2/12/23 noted the resident's skin was intact.
On 3/13/23 at 11:15 a.m., Resident #67 was observed sitting on the edge of her bed. Resident #67 said
she had multiple skin tears. A dressing dated 3/2/23 was observed to the right shoulder, and a dressing to
the right leg, and left upper arm dated 3/7/23.
On 3/15/23 at 8:14 a.m., Resident #67 was observed with the same dressing to the right shoulder dated
3/2/23, the right leg dated, and left upper arm dated 3/7/23.
Review of the skin evaluation forms completed on 2/18/23, 2/25/23, 3/3/23, and 3/12/23 did not note skin
tears to the right shoulder, the right leg and left upper arm.
Review of the Treatment Administration Record (TAR) for 3/23 for Resident #67 failed to reveal treatment
orders for the right shoulder the right leg and left upper arm.
The TAR had a weekly treatment order for a skin tear starting on 3/3/23 and ending on 3/15/23. The TAR
did not specify the location of the skin tear.
On 3/15/23 at 8:16 a.m., a joint observation of the dressings to Resident #67's right shoulder, right leg and
left upper arm was made with Licensed Practical Nurse (LPN) Staff AA, and the 3rd-floor Unit Manager.
Both nurses verified the dressing to the right shoulder was dated 3/2/23 and the dressings to the right leg
and left upper arm were dated 3/7/23.
LPN Staff AA said the skin tear protocol was to change the dressing every seven days. She confirmed the
dressing to the right shoulder was dated 3/2/23 and had not been changed in 13 days. She also confirmed
the dressing to the right leg and left upper arm were dated 3/7/23 and had not been changed in eight days.
On 3/16/23 at 1:04 p.m., the Unit Manager said she would investigate why the treatment to the right
shoulder, the right leg and the left upper arm were not done.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105966
If continuation sheet
Page 7 of 15
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105966
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Larsen Health Center
13880 Shell Point Plaza
Fort Myers, FL 33908
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0687
Provide appropriate foot care.
Level of Harm - Minimal harm
or potential for actual harm
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.
Residents Affected - Few
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 resident was cognitively impaired and dependent on staff for activities of daily living. Resident #81 did
not reject care.
Review of the physician's progress notes revealed on 9/8/22 Resident #81 saw the podiatrist. The podiatrist
documented a diagnosis of atherosclerosis of the arteries of the extremities (thickening of the arteries,
causing reduced blood flow to extremities).
The podiatrist documented Resident #81 had a painful corn to the left foot; ten mycotic (nail fungus) painful
incurvated, inflamed toenails; ingrown toenails; pain in left foot; pain in right toes; pain in left toes.
The podiatrist performed a sharp debridement (removal of dead tissue) of the keratotic lesion (corn). The
podiatrist documented Resident #81 needed to be seen again in two months.
Review of the Social Work Progress Note dated 2/22/23 revealed a care plan meeting was held with the
resident's healthcare surrogate (HCS). The HCS said she was worried about Resident #81's toenails. The
HCS stated she would check Resident #81's toes and let them know if she needs to be seen.
On 3/15/23 at 12:55 p.m., during a telephone interview, Resident #81's Health Care Surrogate (HCS) said
the facility was not taking care of Resident #81's toenails.
On 3/16/23 at 10:35 a.m., observation of Resident #81's toenails with Clinical Coordinator Registered
Nurse (RN) Staff L revealed long, thick, yellow toenails on both feet. RN Staff L said toenail clippers would
not be effective for trimming the toenails, and Resident #81 should be seen by the podiatrist.
On 3/16/23 at 12:29 p.m., RN Staff L verified on 9/8/22 the podiatrist requested a two month follow up
appointment for Resident #81. She said the facility failed to arrange the two month podiatry follow up
appointment, and Resident #81 did not receive the necessary foot care.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105966
If continuation sheet
Page 8 of 15
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105966
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Larsen Health Center
13880 Shell Point Plaza
Fort Myers, FL 33908
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0687
On 3/16/23 at 2:58 p.m., the Administrator said it has been a problem arranging and transporting Memory
Care Residents to and from the podiatrist for a few months.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105966
If continuation sheet
Page 9 of 15
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105966
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Larsen Health Center
13880 Shell Point Plaza
Fort Myers, FL 33908
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
**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 staff assignment sheets will be adjusted as needed to reflect current and appropriate
fall interventions. The nursing staff will observe, interview as appropriate and document resident's post fall
status as well as effectiveness of identified fall interventions in place on each shift for the next 3 days in the
resident record.
It is important to recognize that on size does not fit all when considering interventions for residents fall
management.
Review of the clinical record revealed Resident #143 had an admission date of 12/26/22 with readmissions
on 1/20/23 and 2/18/23 with diagnoses including Alzheimer's, dementia, left hip fracture, frequent falls, and
aphasia (loss of ability to express or understand speech).
The admission Minimum Data Set (MDS) (standardized assessment tool that measures health status in
nursing home residents) with an assessment reference date of 1/26/23 documented Resident #143
required limited assistance of one person with bed mobility, transfers, and ambulation. Resident #143 was
frequently incontinent of urine, and bowel. A urinary and bowel toileting program was not being used to
manage the resident's incontinence.
The MDS noted a Brief Interview for Mental Status (assessment of a resident's cognitive function) was 99
indicating the resident was unable to complete the interview.
The facility initiated a care plan on 12/26/22 indicating Resident #143 was at risk for falls due to weakness,
low endurance and decreased mobility as a result of acute or chronic health conditions and aphasia.
The care plan interventions on 12/28/22 included to orient resident to room, call light, and need to call for,
and wait for assistance, maintain adequate lighting in resident's room, keep bed in lowest position possible,
attempt to keep resident as active in activities during the day as resident will allow.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105966
If continuation sheet
Page 10 of 15
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105966
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Larsen Health Center
13880 Shell Point Plaza
Fort Myers, FL 33908
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
The facility fall assessment dated [DATE] determined the resident was a moderate risk for falls.
Level of Harm - Actual harm
Review of the incident reports revealed:
Residents Affected - Few
On 1/20/23 at 6:30 a.m., Resident #143 was found on the floor in her room and was unable to state what
she was doing at the time of the fall. Resident #143 sustained a skin tear to the right side of her abdomen.
On 1/21/23 at 3:31 p.m., Unit Manager, Licensed Practical Nurse (LPN) Staff F completed the investigation
follow up and documented Resident #143 was agitated, had dementia and restlessness. LPN Staff F
documented, IDT (interdisciplinary team) meeting regarding found on floor next to bed. Regular mattress in
place. Work for grab bars placed. Intervention: Staff to ensure wheelchair to be placed at bedside.
The facility lacked documentation of an investigation to determine the root cause of the fall and implement
appropriate interventions to prevent further avoidable falls.
On 1/24/23 at 1:00 a.m., Resident #143 was found on the floor in her room. After assessment, a bump
noted on the back of the head. Resident complained of pain. Tylenol given as ordered and ice pack applied.
On 1/25/23 at 4:48 p.m., LPN Staff F completed the investigation follow up and documented Visual
reminder to use call bell for assistance.
There was no documentation of an investigation to determine the root cause of the fall and implement
appropriate interventions to prevent further avoidable falls.
On 1/29/23 at 6:25 p.m., Resident #143 was found sitting on the floor. The incident report documented this
nurse was notified by neighboring resident family that she heard a big bang. Upon arrival resident was
observed sitting, guarding LLE (left lower extremity) and being in distress/teary. Three wheeled walker next
to her. The nurse documented the resident reported pain pointing to the left knee. The nurse assessed
Resident #143 and documented the left lower extremity appeared shorter and rotated with substantial
bruising.
The resident was sent to the local hospital emergency room (ER). Review of the ER nursing documentation
revealed Resident #143 had left knee swelling and laceration to the left forehead. A left knee x-ray was
obtained. The x-ray report documented no acute fracture or dislocation.
The clinical impressions were closed head injury, contusion, acute pain of the left knee.
Resident #143 was transferred back to the facility.
On 2/27/23 at 1:03 p.m., (29 days after the fall), LPN Staff F completed the investigation follow up and
documented, IDT meeting regarding fall 1/29/23. Resident returned from ER (Emergency Room) continue
B&B (bowel and bladder) observation and set up B&B schedule for resident.
The clinical record lacked documentation a bowel and bladder schedule was initiated for the resident.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105966
If continuation sheet
Page 11 of 15
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105966
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Larsen Health Center
13880 Shell Point Plaza
Fort Myers, FL 33908
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
The admission MDS with a target date of 2/23/23 noted a toileting program was not being used to manage
the resident's urinary and bowel continence.
Level of Harm - Actual harm
Residents Affected - Few
On 3/16/23 at 11:40 a.m., Unit Manager LPN Staff F said the root cause of the fall on 1/29/23 was Resident
#143 got up to go the bathroom because she does not get up unless she has to go to the bathroom. The
resident is nonverbal and took herself to the bathroom. She was found next to the bed with the walker so, I
figured she was going to the bathroom. The investigation as to why she fell was she was getting up to go to
the bathroom it is what she always does. LPN Staff F confirmed there was no documentation the bowel and
bladder schedule was initiated.
On 2/10/23 at 9:00 p.m., a facility incident report documented 2/9/23 resident complained of left hip pain,
primary nurse notified, some bruising and edema on left hip.
Resident #143 was sent to the local hospital emergency room where an x-ray result documented an acute
left hip fracture. The resident was admitted to the hospital and had a surgical repair of the left hip fracture
on 2/12/23.
On 3/14/23 at 12:57 p.m., an observation showed Resident #143's room door was closed and no staff were
observed in the hallway. The resident was in her room alone and the call light was on the floor out of her
reach.
On 3/15/23 at 9:37 a.m., Certified Nursing Assistant (CNA) Staff G said Resident #143 will yell, no words
just screams when she wants assistance. She is able to use the call light, but she does not. The CNA said
Resident #143 was able to use the toilet and ambulates with the rolling walker and assistance. Staff G said
the resident will go to a few activity programs a week and she has family and friends who come to visit her.
She does not speak but she understands you. I was not here when she fell and hurt her hip. She could walk
with the walker but not by herself, she always needed help. The CNA said, Resident #143 did not like to get
out of bed, and she will yell out.
On 3/16/23 at 9:40 a.m., the Administrator confirmed the incident report did not specify if the care plan
interventions were in place at the time of the fall on 1/29/23. The Administrator confirmed Resident #143
had multiple falls and said, we review the falls and update the care plan.
Review of Resident #143's care plan showed the care plan interventions were not updated after the falls on
1/20/23, 1/24/23 and 1/29/23.
On 3/16/23 at 1:53 p.m., the Rehab Director said prior to Resident #143 sustaining the left hip fracture she
required supervision with bed mobility and stand by assistance. She was ambulating with supervision
walking household distance of 100 feet with a three wheeled walker and contact guard. She was not able to
toilet herself and was not able to dress her lower body. The Rehab Director said as long as someone was in
the general area with eyes on her, she was safe to ambulate.
The Rehab Director confirmed Resident #143 had a decline in ambulation and activities of daily living since
she sustained the left hip fracture.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105966
If continuation sheet
Page 12 of 15
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105966
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Larsen Health Center
13880 Shell Point Plaza
Fort Myers, FL 33908
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0700
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
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.
3. Review of the clinical record revealed Resident #28 had a readmission date of 2/10/23 with diagnoses
including hypertension, fracture of the right femur and morbid obesity.
A Grab Bar Data Collection form dated 2/10/23 documented intervention lower bed to the floor or provide a
low bed. There was no documentation in the clinical record of alternate interventions were attempted before
the grab bars were applied to the bed.
Random observations on 3/14/23 at 12:39 p.m., and 3/15/23 at 8:56 a.m., noted Resident #28 in a regular
bed at regular height, with grab bars on both sides in the raised position.
4. Review of the clinical record revealed Resident #143 had a readmission date of 2/18/23 with diagnoses
including muscle weakness, fracture of the left femur/left hip and repeated falls.
A Grab Bar Data Collection form dated 2/18/23 documented grab bars were not recommended.
On 3/14/23 at 12:57 p.m., Resident #143 was observed in a low bed with grab bars in the raised position on
both sides of the bed.
5. Review of the clinical record revealed Resident #554 had an admission date of 3/8/23 with diagnoses
including muscle weakness and sever protein calorie malnutrition.
A Grab Bar Data Collection form dated 2/8/23 documented lower bed to the floor or provide a low bed.
There was no documentation in the clinical record of alternate interventions were attempted before the grab
bars were applied to the bed.
On 3/14/23 at 2:55 p.m., Resident #554 was observed in a regular bed with grabs on both side of the bed in
the raised position.
On 3/16/23 at 9:03 a.m., in an interview the Administrator confirmed there was no documentation of
alternate interventions attempted before the grab bars were applied for Residents #28, #143 and #554.
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
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105966
If continuation sheet
Page 13 of 15
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105966
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Larsen Health Center
13880 Shell Point Plaza
Fort Myers, FL 33908
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0700
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
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 of Resident #97's
bed. Certified Nursing Assistant (CNA) Staff BB said resident had the grab bars for as long as she has
worked with her.
On 3/14/23 at 10:42 a.m., observed bilateral grab / side rails on both sides of Resident #97 bed. CNA Staff
Q said she has had them as long as she has worked with her.
2. Clinical record review for Resident #110 documented an initial admission to the facility of 7/7/22 and
current admission of 7/12/22. A Grab bar data collection form was completed on 7/8/22 at 12:24 a.m. An
order was entered on 7/13/22 at 5:51 p.m. for the resident to have bilateral grab bars. A consent for side rail
device was signed by resident 7/8/22.
On 3/13/23 at 1:30 p.m., observed Resident #110 in bed with bilateral grab bar side rails elevated on both
sides of bed.
On 3/14/23 at 10:07 a.m., Resident #110 observed in bed with bilateral grab bar side rails elevated.
Resident said she did not recall signing a consent or having risks reviewed with her before they were
installed.
On 3/15/23 at 12:00 p.m., CNA Staff CC said resident #110 has had the side rails as long as she has been
on their floor. The CNA said, Most of our residents have the grab bars so they can hold on to them when we
are doing care. I don't know what is done to decide who gets grab rails or not. That is up to the nurses.
On 3/15/23 at 1:15 p.m., interviewed Registered Nurse (RN) Staff DD about Resident #97 and Resident
#110 having grab bars on their bed. RN Staff DD said, we have a grab bar assessment that is done, we get
an order and consent. RN Staff DD did not know of any interventions attempted prior to installation of the
grab bars side rails.
On 3/15/23 at 4:00 p.m., the DON confirmed Resident #97 and Resident #110 had grab bars in place. She
said, they are for bed mobility. The DON said she would have to look into interventions attempted prior to
the installation of the grab bars. She said she was not sure what was meant by interventions attempted.
The DON said, They are screened by therapy and nursing. I will need to look into that.
On 3/16/23 at 9:32 a.m., the DON confirmed there were no documented interventions attempted prior to
installing the grab bar on residents' beds. She confirmed the grabs bar were started on the day of
admission for Resident #97 and #110.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105966
If continuation sheet
Page 14 of 15
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105966
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Larsen Health Center
13880 Shell Point Plaza
Fort Myers, FL 33908
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0909
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
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.
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
mattress had two positions, wide and narrow but he did not measure for gaps between the mattress and the
grab bars. He said a bed check was done quarterly and every movable component is checked. Grab bars
are already on the beds and are either up or down, they are called pivoting plastic grab bars. The
Maintenance Manager said routine maintenance of 20 beds was conducted monthly. The Maintenance
Manager was not able to locate documentation of the routine bed checks for safety of the grab bars. He
said he had no policy for use of the grab bars and said he did not check the grab bars and the mattress for
entrapment areas. He confirmed he did not measure for gaps that might be present between the mattress
and the grab bars.
On 3/16/23 at 12:00 p.m., in an interview the Administrator confirmed the maintenance team was not
measuring the beds and grab bars for areas of potential entrapment.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105966
If continuation sheet
Page 15 of 15
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Back to topCitations
16 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
F680 - The activities program must be directed by a qualified professional
Ensure the activities program is directed by a qualified professional.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F687 - Foot care
Provide appropriate foot care.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F700 - Bed Rails
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.
F909 - Conduct Regular inspection of all bed frames, mattresses, and bed
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.
- 0223GeneralS&S Fpotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- 0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0541GeneralS&S Fpotential for harm
Install properly constructed and protected linen or trash chutes.
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
F914 - Be designed or equipped to assure full visual privacy for each
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
F915 - Buildings must have an outside window or outside door in every
Have proper power supply for life support equipment.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
- 0929GeneralS&S Epotential for harm
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
FAQ · About this visit
Common questions about this visit
What happened during the March 16, 2023 survey of LARSEN HEALTH CENTER?
This was a inspection survey of LARSEN HEALTH CENTER on March 16, 2023. The surveyor cited 16 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LARSEN HEALTH CENTER on March 16, 2023?
Yes, 16 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Respond appropriately to all alleged violations."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.