Inspection·August 16, 2023

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 and staff interviews, the facility failed to ensure insulin vials and pens were properly labeled and dated when opened, in medication carts for 1 (C wing) of 3 wings reviewed. Without an open date on the insulin there was no way to know when it would expire. This had the potential for residents to receive medications that could create hazardous health consequences. The findings included: On 8/16/23 at 9:00 a.m., during an observation of medication cart #3 on the C wing with Registered Nurse (RN) Staff A the following was observed: 1. One open bottle of Glargine insulin for Resident #950 without a date of when it was opened. The pharmacy label documented to discard after 28 days. Photographic evidence obtained. 2. One open bottle of Glargine Insulin in the medication with no resident identification label and no open date. Photographic evidence obtained. 3. One open bottle of Aspart insulin for Resident #800 without a date of when it was opened. The findings were verified by RN Staff A. 4. One Aspart insulin pen for Resident #850 without a date of when it was opened. The findings were verified by RN Staff A. On 8/16/23 at 9:30 a.m., during an observation of medication cart #1 on the C wing with Licensed Practical Nurse (LPN) Staff B the following was observed: 5. One open bottle of Glargine insulin for Resident #799 with an open date of 6/23/23. The Pharmacy label specified to discard the medication 28 days after opening. (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 2 Event ID: 105363 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 08/16/2023 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)