Health inspection·December 1, 2022

F 0580 11/30/22:135.0 lbs. Level of Harm - Minimal harm or potential for actual harm On 11/30/22 at 9:49 a.m., in a telephone interview the Registered Dietitian (RD) stated Resident #50 experienced a 7.6 lbs. weight loss from September 2, 2022, to October 18, 2022, and lost another 5.6 pounds as of 11/30/22. The RD stated she did not inform the Physician nor asked the Charge Nurse to do so. She stated, I missed this one completely. Residents Affected - Few On 12/1/22 at 10:50 a.m., the Administrator stated it was her expectation for the attending physician to see a resident and explore further interventions when a resident had a significant weight loss to increase or maintain the resident's weight. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105363 If continuation sheet Page 2 of 16 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 105363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charlotte Bay Rehab and Care Center 4033 Beaver Lane Port Charlotte, FL 33952 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and policy review the facility failed to ensure timely report of injuries of unknown origin to the State Survey Agency for 1 (Resident #84) of 4 residents reviewed. The findings included: A review of the facility, Policy, Procedures and Information, with an effective date of 4/1/2022 stated, it will be the policy of this facility to ensure that all alleged violations of Federal or State laws, which involve . injuries of undetermined source.not in accordance with regulation to treat resident's symptoms be reported immediately to the Administrator/DNS/Abuse coordinator/designee. Appropriate agencies will be notified in accordance with existing laws. An injury of unknown source is an injury that was not observed by any person and the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury, or the location of the injury, or the number of injuries observed at one particular point in time, or the incidence of injuries over time. On 11/28/22 at 11:03 a.m., Resident #84 was observed lying on her left side, facing the window, her arm exposed to air. A large approximately 3-inch skin tear was observed on her right arm with a small bruise just below it. Resident #84 was awake with eyes open but did not respond to simple questions. On 11/28/22 at 3:14 p.m., Resident #84 was observed with a dated and initialed dressing to her right forearm. On 11/29/22, a clinical record review noted resident #84 was admitted on [DATE]. Resident #84 diagnoses included Dementia, Muscle weakness, and routine healing of a right hip fracture. An event report dated 11/27/22 noted, resident found with skin tear to left forearm in bed. On 12/01/22 at 11:46 a.m., the Director of Nursing (DON) confirmed she could not tell by the information in the risk report how the skin tear occurred and said the resident was not able to assist with care and express how the injury occurred. The DON said the injury should have been reported and investigated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105363 If continuation sheet Page 3 of 16 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 105363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charlotte Bay Rehab and Care Center 4033 Beaver Lane Port Charlotte, FL 33952 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 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** Based on record review, staff interviews and policy review the facility failed to have documentation of investigation of an injury of unknown origin for 1 (Resident #84) of 4 sampled residents. Residents Affected - Few The findings included: A review of the facility Policy, Procedures and Information with an effective date of 4/1/2022 stated, it will be the policy of this facility to ensure that all alleged violations of Federal or State laws, which involve mistreatment, neglect, abuse, injuries of undetermined source .not in accordance with regulation to treat resident's symptoms be reported immediately to the Administrator/DNS/Abuse coordinator/designee. Appropriate agencies will be notified in accordance with existing laws. An injury of unknown source is an injury that was not observed by any person and the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury, or the location of the injury, or the number of injuries observed at one particular point in time, or the incidence of injuries over time. On 11/28/22 at 11:03 a.m., Resident #84 was observed lying on her left side, facing the window, her arm exposed to air. A large approximately 3-inch skin tear was observed on her right arm with a small bruise just below it. Resident #84 was awake with eyes open but did not respond to simple questions. On 11/28/22 at 3:14 p.m., Resident #84 was observed with a dated and initialed dressing to her right forearm. On 11/29/22, a clinical record review noted resident #84 was admitted on [DATE]. Resident #84 diagnoses included Dementia, Muscle weakness, and routine healing of a right hip fracture. An event report dated 11/27/22 noted, resident found with skin tear to left forearm in bed. On 12/01/22 at 11:46 a.m., the Director of Nursing (DON) confirmed she could not tell by the information in the risk report how the skin tear occurred and said the resident was not able to assist with care and express how the injury occurred. The DON confirmed she did not investigate the event and that currently it was day five since the skin tear was identified. The DON said the injury should have been investigated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105363 If continuation sheet Page 4 of 16 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 105363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charlotte Bay Rehab and Care Center 4033 Beaver Lane Port Charlotte, FL 33952 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the clinical record for Resident #17 revealed a readmission date of 8/16/22. The record contained a quarterly minimum data set (MDS) dated [DATE] documented a brief interview for mental status (BIMS) score of 15, indicating intact cognition. The MDS documented Resident #17 required extensive assistance of 1 with toileting, and supervision and assistance of 1 with ambulation in her room. The MDS identified Resident #17 was occasionally incontinent of bowel and bladder and was not on a toileting program. On 9/11/22 at 5:30 a.m., Resident #17 was found on the floor in her room. The Event Details form documented, the nurse heard the closed room door rattling and slowly opened it to find the resident on the floor behind the door, kicking the door in distress, saying I fell, and I'm hurt. Resident has a large hematoma on right side of head, small amount of bleeding in hair. Resident complains of acute back pain. The resident was transferred to the local hospital emergency room where she was diagnosed with a T 11 (thoracic spine) compression fracture and anterior wedge compression fracture T 12. The resident had surgical repair of the fracture on 9/12/22. The care plan initiated 10/31/20 (revised 8/25/22), identified Resident #17 was at risk for falls related injury as determined to generalized weaknesses, anemia, and muscle weakness. The interventions included assist for toileting and transfers as needed and place call bell within easy reach. Complete review of the clinical record failed to reveal documentation of a fall assessment and the facility was not able to provide one at the time the survey completed. On 11/28/22 at 10:30 a.m., Resident #17 said she fell and fractured her back while at the facility. She said she was not sure when she fell but said it was recently. Resident #17 said sometimes it takes more than 15 minutes before staff answer her call light. She said she had back pain due to breaking her back in the fall. On 11/30/22 at 2:23 p.m., the Director of Nursing (DON) said we met with the interdisciplinary team every morning and reviewed falls and updated the care plan. The care plan for Resident #17 documented on 2/27/18 to observe for appropriate footwear, use nonskid socks. On 10/10/22 the care plan was updated again to encourage to wear nonskid socks when not in bed. The DON said Resident #17 was readmitted to the facility on [DATE] after a fall at home, she was here for therapy, and she was doing well. The resident was taking care of herself and was going to discharge back home in a few days, but she fell and broke her back. The DON confirmed there was no documentation of an investigation into the cause of the residents fall to implement appropriate interventions to prevent further falls. On 12/1/22 8:24 a.m., Certified Nursing Assistant (CNA) Staff A said before her fall, Resident #17 used to get things done herself we would supervise her. When walking to the bathroom or in the hall we supervised her, she was going to be discharged home. CNA Staff A said, now she can do things on her own, but we supervise her for safety. On 12/1/22 at 8:36 a.m., Resident #17 said the night she fell, she couldn't reach the call light. The door was closed and it was dark. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105363 If continuation sheet Page 5 of 16 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 105363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charlotte Bay Rehab and Care Center 4033 Beaver Lane Port Charlotte, FL 33952 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some She said she got up unassisted and tripped over the bedside table, fell and hurt herself. It took over 15 minutes form for someone to come and get her off the floor. 3. A review of the clinical record for Resident #48 revealed the resident was admitted to the facility on [DATE]. The record showed a quarterly MDS dated [DATE] documented the resident had a BIMS score of 15, indicating intact cognition. The MDS documented the resident required extensive assistance of 1 with bed mobility, transfers, toileting, dressing, and personal hygiene. The MDS documented the Resident was frequently incontinent of bowel and bladder and was not on a toileting program. The care plan initiated 2/27/18 identified the resident was at risk for fall related injury due to poor sitting and standing balance, unsteady gait, and dementia. The interventions included to observe for appropriate footwear; use nonskid socks, remind resident to request assistance prior to ambulation and or transfers, remind resident to lock brakes on wheelchair. Complete review of the clinical record failed to reveal documentation of a fall assessment and the facility was not able to provide one at the time the survey completed. On 10/9/22 at 2:37 p.m., Resident #48 was found on the floor. The Event Details form documented; Resident observed lying on bathroom floor. Resident sent to emergency room for further evaluation. A nursing progress noted dated 10/9/22 at 3:25 p.m., documented the resident observed lying on floor. Resident stood up in bathroom and loss her balance and fell on floor. Denies pain or discomfort. Able to move all extremities without discomfort. Some skin discoloration noted on arms and abdomen. Resident did not hit her head. Her legs are weak. Resident was educated about keeping socks or shoes on feet when going to the bathroom. A nursing progress note dated 10/9/22 at 7:48 p.m., documented the resident complained of pain to left elbow. New order received to obtain x-ray of left elbow. On 10/10/22 at 1:09 p.m., the nursing progress note documented post fall, resident complained of left elbow pain, area noted swollen, slight red. X-ray was still pending. The physician issued an order to send the resident to the emergency room for evaluation. The resident was transferred to the local hospital emergency room where she was diagnosed with a left olecranon (part of the ulna that creates a hinge for elbow movement) fracture and was admitted to the hospital. On 11/28/22 at 1:58 p.m. Resident #48 was observed sitting in a wheelchair in her room. The resident had a sling on her left arm. Resident #48 said she had a fall in the bathroom a few months ago and had a fracture in the left shoulder. She said she had fallen and pointed to the middle of the room, floor. Resident #48 said she did not know how she fell, and said I had to use the bathroom. She said she did not know if she had used the call light. On 11/30/22 at 11:37 a.m., in an interview the DON, said she had no documentation of what interventions were in place when the resident fell and she did not have documentation of an investigation of the fall. 11/30/22 at 1:29 p.m., the DON said Resident #48 was working with therapy at the time of the fall and was independent with her care needs. The DON said the care plan was the documentation that the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105363 If continuation sheet Page 6 of 16 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 105363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charlotte Bay Rehab and Care Center 4033 Beaver Lane Port Charlotte, FL 33952 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 care plan interventions were in place at the time of the fall. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, review of the facility's policies, staff, and resident interview the facility failed to have documentation of analysis of falls to implement appropriate interventions to prevent avoidable falls and fall related injuries for 3 residents (#17, #48, #76) of 4 residents reviewed who sustained falls at the facility. Residents Affected - Some The findings included: A review of the facility policy and procedure, Falls Policy, revised 7/29/2022 stated, The intent of this policy is to ensure the facility provides an environment that is free from accident hazards over which the facility has control to prevent avoidable falls. The policy further states, all residents will have a comprehensive fall risk assessment on admission, quarterly, annually and with significant change in condition. Appropriate care plan interventions will be implemented and evaluated as indicated by assessment. A comprehensive care plan will be implemented based on fall risk evaluation score with an individual goal and interventions specific to each resident. The care plan will be reviewed following each fall, quarterly, annually and with each significant change. The facility fall guidelines stated if a fall occurs the following actions will be taken, evaluate the resident including neuro-checks, pain assessment, range of motion, skin, joint, extremities and vital signs. Neuro-checks x (for) 72 hours will be initiated for all unwitnessed falls. Once resident is stabilized nurse will conduct a Fall Huddle will all staff working on that hallway. Interventions must be initiated. Enter residents name on 24-hour report for minimum of 72 hours for follow up charting on every shift. 1. Review of the clinical record showed resident #76 had an admission date of 4/8/22 and had severe cognitive impairment. Review of fall documentation showed resident #76 sustained a fall at the facility on 8/30/22, 9/5/22, 11/18/22. Review of the progress notes revealed documentation on 11/18/22 at 10:55 a.m., the Certified Nursing Assistant (CNA) notified the nurse the resident was agitated and trying to get out of bed repeatedly. While checking for the resident's PRN (as needed) order the CNA approached her and said the resident had fallen. The nurse documented when she entered the room the resident was sitting upright on the floor mat, leaning her left side against the right side of the bed. The resident was transferred to bed. A care plan intervention for resident #76 was last updated 9/9/22 which included a therapy evaluation for positioning in wheelchair. On 11/28/22, at 10:21 a.m., resident #76 was sitting in bed and stated she was, not so good today, I fell and hit my head today, people came and looked at it. Resident pointed to swelling lump on forehead. Resident noted to have large golf ball size lump in right center of her forehead with abrasion present. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105363 If continuation sheet Page 7 of 16 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 105363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charlotte Bay Rehab and Care Center 4033 Beaver Lane Port Charlotte, FL 33952 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 Level of Harm - Minimal harm or potential for actual harm On 11/28/22, at 12:21 p.m., resident #76 daughter was at the bedside and said the nurse practitioner and hospice agency were planning to put a different mattress on the bed with sides. The clinical record lacked documentation of implementation of post fall assessment, updated interventions or neuro-checks after the fall on 11/28/22. Residents Affected - Some On 11/28/22 at 3:22 p.m., resident #76 progress note stated, resident is complaining of a headache, Tylenol and Tramadol given. On 12/1/22 at 11:21 a.m., Licensed Practical Nurse (LPN), Staff I said she was assigned to resident #76. She said routine care for unwitnessed fall included neuro-checks (neurological checks) for 72 hours or send the resident out, alert the CNA what to watch for. Staff I said she was not aware Resident #76 had a fall. After reviewing the progress notes, LPN Staff I verified neurological checks were not initiated on 11/28/22 after the resident sustained a fall and hit her head. She said Resident #76 was taking Plavix (blood thinner) and should have had neuro-checks started. On 12/1/22 at 11:46 a.m., the Director of Nursing (DON) said taking Plavix would put Resident #76 at increased risk for bleeding after the fall. She said neurological checks should have been initiated immediately. The DON said she will be contacting the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105363 If continuation sheet Page 8 of 16 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 105363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charlotte Bay Rehab and Care Center 4033 Beaver Lane Port Charlotte, FL 33952 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of policies and procedures, resident and staff interviews, the facility failed to monitor the weight and implement intervention to prevent ongoing weight loss for 1 (Resident #50) of 4 sampled residents identified with significant weight loss. Residents Affected - Few Resident #50 experienced a 7.6% significant weight loss in 46 days and continued to lose weight without appropriate interventions and monitoring. The findings included: The facility's weight and measuring height policy with an effective date of 3/22/22 noted, Guidance and best practice . Significant weight changes are considered significant changes in condition and require facility staff assessment/intervention .Facility staff will notify the charge nurse and Registered Dietician of 5% gain or loss . notify physician of weight change . Review of the clinical record indicated Resident #50 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, and unspecified severe protein-calorie malnutrition. The Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 8/31/22 noted the resident's cognition was intact. The resident was coded as having been 67 inches tall and weighed 144 pounds. The resident was receiving a regular diet. Review of Resident #50's care plan initiated edited on 9/1/22 noted the resident was at risk for malnutrition related to but not limited to advanced age, abnormal labs, inadequate oral intake, history of failure to thrive, anorexia, cachexia (Complex syndrome causing ongoing muscle loss), and Chron's disease (Chronic inflammatory disease of the intestines). The goal was to maintain adequate nutritional status as evidenced by maintaining weight and no signs or symptoms of malnutrition. The interventions included to administer nutritional support as ordered, report to the physician signs and symptoms of malnutrition, significant weight loss. Review of the Nutritional Review with an effective date of 11/21/22 revealed documentation the resident's weight was down significantly for one month and stable for three and six months. The Registered Dietitian documented the resident had fair oral intake, she will add health shakes 120 milliliters twice a day and will obtain weekly weights. Resident #16's orders did not list the health shakes and weekly weight. On 11/28/22 at 10:03 a.m., Resident #50 said he has lost weight in the last month, adding, I am skin and bone. Review of the weights and vitals summary revealed the following weights documented for Resident #50: 9/2/22: 148.2 lbs. (pounds). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105363 If continuation sheet Page 9 of 16 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 105363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charlotte Bay Rehab and Care Center 4033 Beaver Lane Port Charlotte, FL 33952 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 0692 10/18/22:140.6 lbs. (a significant weight loss of 7.6% in one month). Level of Harm - Minimal harm or potential for actual harm 11/30/22:135.0 lbs. Residents Affected - Few On 11/30/22 at 9:49 a.m., a phone interview was conducted with the Registered Dietitian (RD). The RD said Resident #50 experienced a 7.6 pounds weight loss from September 2, 2022, to October 18, 2022, and lost another 5.6 pounds as of 11/30/22. The RD identified the weight loss as severe and said Resident #50 should be on weekly weights and supplements. The RD said she documented her recommendations and findings on her notes on 11/21/22 but did not inform the physician of the weight loss. She said, I missed this one completely. The Dietitian said she assessed the resident and recommended health shakes and nursing had not contacted the physician to order the shakes as of now. She verified the nursing staff did not obtain weekly weights for Resident #50 as per her recommendation. On 11/30/22 at 10:10 a.m., the Director of Nursing (DON) said she was not aware of Resident #50's significant weight loss. The DON said when a resident experiences significant weight loss, the expectation is to put interventions in place to encourage weight gain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105363 If continuation sheet Page 10 of 16 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 105363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charlotte Bay Rehab and Care Center 4033 Beaver Lane Port Charlotte, FL 33952 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on record review, and staff interviews, the facility failed to ensure ongoing monitoring for complications, coordination and response to the dialysis center's multiple requests for weight monitoring for 1 (Resident #96) of 1 sampled resident receiving dialysis. Residents Affected - Few The findings included: A review of clinical record for Resident #96 showed a date of admission of 4/26/2022, and readmission of 11/15/22 with diagnoses including end stage renal disease, and dependence on renal dialysis (procedure to remove waste products an excess fluid from the blood). The physician orders included to check the resident's weight before and after dialysis. The care plan initiated on 11/19/22 documented the resident needed hemodialysis related to renal failure. The interventions included to obtain weight per protocol. A review of the clinical record revealed the facility used a Dialysis Hand off Communication report to coordinate with the dialysis center. The form included a section to document pre and post dialysis weight. On 10/26/22 the dialysis center documented on the form, We need the weight: Please report weight to dialysis. On 10/27/22 the dialysis center documented on the form, Please weigh. On 10/31/22 the dialysis center documented on the form, Can you please weigh and report weight to dialysis. On 11/2/22 the dialysis center documented on the form, Please weigh and report to dialysis. The dialysis communication forms revealed no documentation of pre-dialysis weights on 10/26/22, 10/27/22, 10/31/22, 11/2/22, 11/3/22, 11/4/22, 11/8/22, 11/11/22, 1/17/22, 11/18/22, 11/21/22, 11/23/22, 11/25/22, and 11/28/22. On 11/2/22, 11/3/22, 11/10/22, 11/11/22, 11/18/22, 11/28/22, 11/30/22 the dialysis communication form did not note the nursing staff evaluated Resident #96 upon return from dialysis. On 12/1/22 at 10:45 a.m., dialysis Registered Nurse (RN) Staff M said pre-dialysis weights were important, and the dialysis center did not always get Resident #96's pre-dialysis weight. On 12/1/22 at 12:04 p.m., Licensed Practical Nurse (LPN) Staff C verified the lack of documentation of pre-dialysis weight for Resident #96 on 10/26/22, 10/27/22, 10/31/22, 11/2/22, 11/3/22, 11/4/22, 11/8/22, 11/11/22, 1/17/22, 11/18/22, 11/21/22, 11/23/22, 11/25/22, and 11/28/22. On 12/1/22 at 12:19 p.m., the Director of Nursing (DON) said the nurse was responsible to ensure pre and post dialysis weights are obtained and communicated to the dialysis center, as they to not have access to the facility's electronic clinical record. The DON verified the lack of documentation Resident #96 was evaluated by the facility nurse upon return from dialysis on 11/2/22, 11/3/22, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105363 If continuation sheet Page 11 of 16 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 105363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charlotte Bay Rehab and Care Center 4033 Beaver Lane Port Charlotte, FL 33952 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 0698 11/10/22, 11/11/22, 11/18/22, 11/28/22, and 11/30/22. 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: 105363 If continuation sheet Page 12 of 16 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 105363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charlotte Bay Rehab and Care Center 4033 Beaver Lane Port Charlotte, FL 33952 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 - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policy and procedures, staff and resident interviews, and record review, the facility failed to ensure 3 (Residents #48, #71, #96 and #101) of 38 residents with bed rails were assessed for alternative interventions prior to the use of bed rails. The facility failed to ensure they had informed the residents and/or their representative of the risks and benefits of bed rails and obtain an informed consent prior to use of the bed rails. The findings included: The facility policy Bed Rails (effective 10/19/22) specified After a facility has attempted to use alternatives to bed rails and determined that those alternatives do not meet the resident's needs, the facility will assess the risks verse benefits prior to use. Any use of bed rails, the facility will do the following: Evaluate the resident. Obtain consent. Documentation in the electronical [sic] medical record (EMR) will include: a. Evaluation for bed rail use; b. Consent for use. 1. On 11/28/22 at 1:58 p.m., and on 11/29/22 at 8:10 a.m., Resident #48 was observed in bed with grab bars on both sides of the upper portion of the bed in the raised position. The clinical record revealed a Consent for use of side rails form dated and signed on 2/1/18 by Resident #48 noting she did not consent to the use of side rails and understood the related liabilities. The clinical record also contained an Excel-Side Rails form with an effective date of 11/9/22 which noted the resident asked to have the side rails while on bed. The form indicated, Side Rails are indicated at the present time. They will promote independence. The alternative listed was reminders to use Call Bell. The clinical record lacked documentation the risks and benefits of the bed rails were reviewed with the resident or representative. 2. On 11/28/22 at 11:15 a.m., and on 11/29/22 at 1:20 p.m., Resident #71 was in bed with grab bars on both sides of the bed in the raised position. Review of the clinical record revealed an Excel-Side Rails form dated 11/7/22 which noted side rails were indicated at the present time, and the resident has not asked to have the side rails while on bed. The form listed alternatives, Reminders to use Call Bell. The form did not list the benefits for the use of the side rails. The record did not contain an informed consent with the benefits and potential negative outcomes for the use of the side rails. 3. On 11/28/22 at 10:30 a.m., and 11/29/22 at 8:24 a.m., Resident #96 was observed in bed with grab bars on both sides of the bed in the raised position. Resident #96 said he did not ask for the grab bars and did not know anything about them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105363 If continuation sheet Page 13 of 16 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 105363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charlotte Bay Rehab and Care Center 4033 Beaver Lane Port Charlotte, FL 33952 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 The clinical record did not contain an informed consent with the benefits and potential negative outcomes for the use of grab bars. On 11/29/22 at 3:27 p.m., the Director of Nursing (DON) said the facility did not have consent forms for the side rails because the devices on the beds were enablers and not side rails, so consent was not necessary. Residents Affected - Few 4. Resident #101 was a [AGE] year-old male with a history of Dementia with severe cognitive impairment. On 11/28/22 at 10:52 a.m., and 11/30/22 at 9:53 a.m., grab bars were observed on both sides of the bed in the raised position. The physician's orders dated 9/27/22 included bilateral assist bars to promote bed mobility and enhance independence. On 11/30/22 at 9:53 a.m., Resident #101 was not able to answer questions related to the use of the bed rails. Review of Resident #101's medical record revealed no evidence of a signed informed consent for use of the side rail. On 12/1/2022 at 5:30 p.m., the Director of Nursing and the Regional Nursing Director verified the lack of an informed consent for the use of side rails for Resident #101. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105363 If continuation sheet Page 14 of 16 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 105363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charlotte Bay Rehab and Care Center 4033 Beaver Lane Port Charlotte, FL 33952 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, review of clinical records, review of facility policies and procedures, resident and staff interviews, the facility failed to ensure the safe storage of medications for 2(Resident #33 and #78) of 2 residents observed with medications at the bedside. The facility failed to dispose of expired medications in 1 medication cart (Unit A-1) of 4 medication carts observed. The findings included: 1. On 11/28/22 at 10:08 a.m., Resident #33 was observed with a large bottle of antacid chewable tablets stored on his bedside table. Resident #33 said he's had them for months and takes them when needed. Photographic evidence obtained. On 11/30/22 at 9:15 a.m., in an interview Licensed Practical Nurse (LPN) Staff C said the resident's wife often and brings in medications. On 11/30/22 at 2:18 p.m., the DON said she was not aware of the bottle of antacid tablets on Resident #33's bedside table, the resident was not assessed to for self-administration of medications. 2. A review of the clinical record for Resident #78 revealed a Self-Administration of Medications assessment form dated 8/30/22. The assessment documented the resident was able to self-administer his inhalers. On 11/28/22 at 10:12 a.m., Resident #78 was observed with three red round pills a clear in a plastic medication cup stored on the bedside table. Resident #78 said the nurse set the cup of pills on the table, and he did not remember what they were for. On 11/30/22 at 8:58 a.m., Registered Nurse (RN) Staff D said the three red pills in the medication cup were probably ibuprofen. On 11/30/22 at 2:18 p.m., in an interview, the DON said Resident #78 was able to self-administer his inhalers, but the nurse should not have left pills at Resident #78's bedside. The facility's policy for Medication Storage. Storage of Medication 2007 noted, Outdated .medications are immediately removed from stock, disposed of according to procedures for medication disposal. The facility provided an Injectable diabetes medication Expiration dates After Opening document as part of their policy for insulin storage which noted opened Humalog-Lispro storage was for 28 days after opening. On 11/28/22 at 11:28 a.m., observation of medication cart Unit A-1 with Registered Nurse (RN) Staff F revealed one insulin Lispro pen belonging to Resident #37. The insulin was opened on 10/28/22 and expired on 11/26/22. photographic evidence obtained. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105363 If continuation sheet Page 15 of 16 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 105363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charlotte Bay Rehab and Care Center 4033 Beaver Lane Port Charlotte, FL 33952 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 0761 Registered Nurse (RN) Staff F stated this insulin should have been thrown out on 11/26/22. Level of Harm - Minimal harm or potential for actual harm On 12/01/22 at 08:57 a.m., Director of Nursing (DON) said the insulin pen should have been discarded on 11/26/22. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105363 If continuation sheet Page 16 of 16