Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies, 2 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 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, review of the clinical record, resident and staff interviews and review of facility policy and
procedures, the facility failed to provide the necessary care and services to maintain personal hygiene for 2
(Residents #252 and #61) of 3 residents reviewed for activities of daily living (ADL's).
Residents Affected - Few
The findings included:
Review of the facility's policy, Activities of Daily Living effective 4/1/22 documented Purpose: To ensure all
residents needs are met in a manner that promotes their quality of life and preferences . A resident who is
unable to carry out activities of daily living shall receive the necessary services to maintain good .
grooming, and personal and oral hygiene .
Review of the clinical record revealed Resident #252 had an initial admission date of 1/3/25 with
readmissions on 1/11/25 and 1/23/25 following hospitalization.
The admission Minimum Data Set (MDS) (standardized assessment tool that measures health status in
nursing home residents) with a target date of 1/11/25 documented Resident #252 required substantial to
maximum assistance with showers and personal hygiene.
The MDS noted Resident #252's cognitive skills for daily decision making were intact with a Brief Interview
for Mental Status Score of 15.
The care plan initiated on 1/15/25 identified Resident #252 had an ADL self-care deficit related to overall
functional decline. The interventions for Resident #252 specified the resident requires substantial to
maximum assistance by one staff with personal hygiene. The care plan instructed to Check nail length and
trim and clean on bath day and as necessary.
On 1/27/25 at 3:49 p.m., Resident #252 was observed in bed. He was unshaven with approximately seven
days of facial hair growth. In an interview during the observation, Resident #252 said before he went into
the hospital, he had a mustache and goatee. He said
a Certified Nursing Assistant (CNA) shaved him once in the last four weeks. The resident said, I could use a
shave, but I have not told anyone. He said he had not received any showers recently, They washed me up
in the bed. Resident #252 said he would enjoy a shower and did not know why he had not received his
scheduled showers.
On 1/28/25 at 10:35 a.m., Resident #252 was observed in his room in bed. The resident remained
unshaved and had approximately one inch of beard growth.
(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 12
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
01/30/2025
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 0677
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
His fingernails were observed to extend approximately ½ inch from the fingertips. They were jagged
and with a brown substance under the nails. The resident said, someone came in and said they would take
care of it today.
Review of the CNA documentation revealed Resident #252 preferred showers and was scheduled for
showers on Tuesdays and Fridays on the 7:00 a.m., to 3:00 p.m., shift. The documentation from 1/4/25
through 1/28/25 revealed the resident received bed baths on 1/4/25, 1/11/25, 1/14/25, 1/15/25, 1/17/25,
1/18/25, 1/19/25, 1/23/25, 1/24/25 and 1/28/25. The only documented shower was on 1/13/25.
On 1/29/25 at 11:22 a.m., in an interview CNA Staff C said resident care information including showers,
splints and care needs was documented in the CNA [NAME] (provides information for safe care) in the
electronic record and that is how she gets resident information. The CNA said she checks residents' daily,
shaves and provides fingernails care as needed.
On 1/29/25 at 12:31 p.m., Resident #252 was observed in his room in a recliner chair. He had a full beard
and mustache of approximately one inch growth. He said he was waiting for someone to shave him.
On 1/29/25 at 3:48 p.m., Resident #252's facial hair growth (beard and mustache) was observed with Unit
Manager Licensed Practical Nurse (LPN) Staff A. LPN Staff A said Resident #252 was readmitted with the
beard and mustache on 1/3/25. She verified the resident had requested to be shaved. Staff A said she
would have staff shave him.
On 1/30/25 at 8:48 a.m., Resident #252 was observed in his bed. He was not shaved. His fingernails
remained long and jagged, extending approximately half an inch. In an interview during the observation,
Resident #252 said, Last night someone came in the room and said they were going to shave me, and they
would get what they needed and left. They never came back so I don't know what is going on.
Review of the clinical record revealed Resident #61 had a readmission date of 12/15/24. Diagnoses
included dementia. Resident #61 required assistance with personal care.
The Quarterly MDS with a target date of 12/15/24 documented Resident #61 was dependent on staff for all
ADL's.
The MDS noted Resident #61's cognitive skills for daily decision making were intact with a Brief Interview
for Mental Status score of 14.
The care plan initiated 9/23/24 and revised 11/1/24 identified Resident #61 had an ADL self-care
performance deficit related to weakness, functional decline, and dementia.
The care plan specified resident was totally dependent on 2 staff for showering/bathing per schedule and
as needed.
On 1/27/25 at 12:34 p.m., Resident #61 was observed sleeping in bed. Her fingernails extended
approximately ½ inch. An accumulation of brown/black substance was observed under the nails.
Facial hair was observed under her chin and the neck area.
On 1/28/25 at 10:57 a.m., Resident #61 was observed with Unit Manager LPN Staff A. Resident #61 was in
bed. The left and right hand fingernails extended approximately 1/2 inch from the fingertips and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105363
If continuation sheet
Page 2 of 12
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
01/30/2025
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 0677
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
remained with a black/brown substance under the nails. The resident's left hand was curled in a fist. In an
interview during the observation, she said she was not able to open her left hand and it was starting to hurt.
The resident's lips were dry. The lower lip was peeling.
Resident #61 said no one had cleaned her teeth for her. She said she did not get out of bed and did not
know why.
LPN Staff A observed the resident's left hand and verified the fingernails extended approximately 1/2 inch
from the fingertips and were curled into a fist. Staff A said Resident #61 was supposed to wear a splint to
the left hand.
On 1/29/25 at 11:21 a.m., CNA Staff B was observed providing care to Resident #61 in her room. In an
interview CNA Staff B said she cleans the resident in bed, provides range of motion to her legs and fixes
the resident's her hair. CNA Staff B said, I do mouth care for her and I speak with her. CNA Staff B said with
two person assist, they use a shower bed to take Resident #61 to the shower room. Staff B said some days
the resident refuses her shower and she cleans her in bed and fixes her hair.
Review of the CNA documentation revealed Resident #61 was scheduled for showers on Wednesdays and
Saturdays during the 3:00 p.m., to 11:00 p.m., shift. The documentation showed on 1/8/25, 1/11/25, 1/18/25
and 1/22/25 Resident #61 did not receive her scheduled showers.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105363
If continuation sheet
Page 3 of 12
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
01/30/2025
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 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, review of the facility policy and procedures, resident and staff interviews, and review of the
clinical record, the facility failed to ensure a resident with limited range of motion receives appropriate
treatment and services to increase range of motion and/or to prevent further decrease in range of motion
(ROM) for 1 (Resident #61) of 1 resident reviewed for limitation in ROM.
The findings included:
The facility policy Nursing-Mobility and Range of Motion with an effective date of 4/1/2022 documented,
Residents with limited ROM should receive treatment and services to increase and or prevent a further
decrease in ROM. As part of the resident's comprehensive assessment the nurse should identify the
resident's.limitations in movement or mobility. The nurse should also identify conditions that place the
resident at risk for complications related to ROM. including.contractures.
The care plan should include specific interventions, exercises and therapies to maintain, prevent avoidable
decline in or improve mobility and ROM.
Review of the clinical record revealed Resident #61 had a readmission date of 12/15/24.
Diagnoses included dementia. Resident #61 required assistance with personal care.
The Quarterly MDS with a target date of 12/20/24 documented Resident #61 was dependent on staff for all
activities of daily living. Resident #61 had limitation in ROM to one side of the upper body and both sides of
the lower body.
The MDS noted Resident #61's cognitive skills for daily decision making were intact with a Brief Interview
for Mental Status score of 14.
The care plan initiated 9/23/24 and revised 11/1/24 identified Resident #61 had an ADL (activities of daily
living) self-care performance deficit related to weakness, functional decline, and dementia.
The care plan interventions specified, Resident to wear a palm guard (protective device) to left hand as
tolerated/as ordered, remove for hygiene and skin checks.
On 1/27/25 at 12:31 p.m., in an interview Resident #61 said she was not able to open her left hand. The
fingers of the left hand were observed curled into a tight fist. Resident #61 was not wearing the palm guard
specified in the care plan to the left hand.
A hand splint was observed on the residents' nightstand.
On 1/28/25 at 10:57 a.m., Resident #61 was observed with Unit Manager LPN Staff A. Resident #61 was in
bed and was not wearing the palm guard to the left hand. The left hand fingernails extended approximately
1/2 inch from the fingertips. The resident's left hand was curled in a fist. In an interview during the
observation, Resident #61 said she was not able to open her left hand and it was starting to hurt. Resident
#61 said she did not know if she had a splint for her hand.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105363
If continuation sheet
Page 4 of 12
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
01/30/2025
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 0688
Unit Manager Staff A said Resident #61 was supposed to wear a splint to the left hand.
Level of Harm - Minimal harm
or potential for actual harm
On 1/29/25 at 12:35 p.m., in an interview Certified Nursing Assistant (CNA) Staff B said she often took care
of Resident #61. Staff B said the resident had a splint for her left hand. She said the therapist shows the
staff how to put apply and remove the splint and how to take care of the splint. She said the information was
on the [NAME] (Provides instructions for safe care).
Residents Affected - Few
Review of the CNA [NAME] revealed, Resident to wear palm guard to left hand as tolerated/as ordered,
remove for hygiene and skin checks.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105363
If continuation sheet
Page 5 of 12
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
01/30/2025
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
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
clinical record review, review of facility's policies and procedures, and staff interviews, the facility failed to
ensure staff followed safety precautions in the care plan while providing care to prevent avoidable fall and
fall related fracture for 1 (Resident #50) of 3 residents reviewed for accidents.
The findings included:
Review of the facility's policy for Falls and Fall Risk-Managing with effective date of 4/1/2022 revealed,
Based on previous evaluations and current data, the staff should identify interventions related to the
resident's specific risks and causes to try to prevent the resident from falling and to try to minimize
complications from falling .
Review of the clinical record for Resident #50 revealed an admission date of 3/6/23. Diagnoses included
Chronic Kidney Disease, and anemia.
Review of the Quarterly Minimum Data Set (MDS) assessment with a target date of 12/2/24 noted the
resident's cognition was intact with a Brief Interview for Mental Status score of 15. The assessment noted
the resident was dependent (Helper does all of the effort. Resident does none of the effort to complete the
activity) for toileting, shower, bathing, upper and lower body dressing. The resident required
substantial/maximal assistance to roll left and right.
Review of the Care Plan for Resident #50 revealed the resident was dependent on staff for activities of daily
living care, transfers and mobility, related to physical limitations. The care plan noted Resident #50 was at
risk for falls related to general weakness, decreased mobility, anemia, Hypertension, Thyroid disorder,
insomnia, and potential side effects of medications. The care plan specified, The resident requires assist
(assistance) of 2 staff to turn and reposition in bed.
Review of the facility's incident investigations revealed on 1/21/25 at approximately 6:30 p.m., Resident #50
rolled out of her bed during patient care, resulting in a fracture of the right distal femur (thigh bone) proximal
to the knee joint. The investigation noted Certified Nursing Assistant (CNA) Staff F was providing a bed
bath to the resident independently. After review of the resident's care profile, it was identified that the
resident was a two person assist for bed mobility.
The investigation noted CNA Staff F failed to follow Resident #50's [NAME] (Provides instructions for safe
care) by assisting the resident with bed mobility by herself and not with the assistance of another staff
member as indicated in Resident #50's medical record.
The investigation noted, The facility concludes from this investigation that this injury to (Resident #50) could
potentially have been avoided had CNA Staff F followed Resident #50's [NAME] as indicated in her medical
record.
Review of the Certified Nursing Assistant [NAME] howed Resident #50 required dependent assistance of
two staff to turn and reposition in bed and used bulateral enablers to maximize independence with turning
and repositioning in bed.
The investigation included an interview with Resident #50 who said CNA Staff F gave her a bed bath.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105363
If continuation sheet
Page 6 of 12
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
01/30/2025
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 - Actual harm
Residents Affected - Few
The CNA was drying her off and changing the sheets. CNA Staff F was standing on the left side of the bed.
Resident #50 said she used the assist bar to roll to the right side of the bed while the CNA changed her
sheets. She did not know what happened. The resident stated one of her legs must have gone too far and
her legs slid off the bed, her right knee hit the floor and then she slid off the bed. Resident #50 stated her
knee hurt and the nurses were providing her with pain medication.
Review of CNA Staff F witness statement revealed Resident #50 asked for a bed bath. When she was
finishing up drying the resident's back while making the bed, Resident #50 used her side rail to pull herself
on her side by herself. She was facing away from me holding the side rail her legs went off the bed. Her
knee hit the floor then I call the nurse ect [sic].
On 1/22/25, Resident #50 was emergently transferred to a local hospital and admitted .
On 1/28/25 at 11:40 a.m., in an interview the Administrator said Resident #50 received a bed bath in her
room. The resident turned herself using the enabler bars. Her legs shifted and she rolled off the bed. CNA
Staff F was changing sheets and drying her off. The Administrator said CNA Staff F did not follow the
requirements outlined in the [NAME], she was still suspended pending investigation.
On 1/30/25 at 9:30 a.m., a joint interview was conducted with the Regional Director of Nursing, the
Administrator, and the Director of Nursing. They all agreed that CNA Staff F failed to provide the required
two person care during a bed bath which resulted in Resident #50 falling out of bed and sustaining a major
injury. They said CNA Staff F was suspended and remains on suspension.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105363
If continuation sheet
Page 7 of 12
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
01/30/2025
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 0690
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure a resident admitted with a urinary
catheter was assessed for removal of the catheter as soon as possible, received services to prevent urinary
tract infections, and had the proper securing device to prevent friction and movement at the insertion site
for 1 (Resident #305) of 2 residents reviewed for urinary catheters.
The findings included:
Review of the facility Policy for Urinary Catheter Care revised 2/21/23 included instructions for infection
control: Be sure the catheter tubing and drainage bag are kept off the floor. Catheter changing instructions
included: Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the
insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.)
Review of the clinical record for Resident #305 revealed an admission date of 1/14/25 for rehabilitation after
pacemaker surgery. Diagnoses included vascular implant infection, diabetes, and chronic kidney disease.
Resident #305 was admitted with a urinary catheter.
The hospital record dated 1/7/25 noted the resident had a recent surgery for infected pacemaker. During
the hospital course, a urinary catheter had been removed shortly before discharge. The bladder scan
showed full bladder; therefore, Foley catheter will be placed. The hospital records did not include a
diagnosis of obstructive uropathy.
The Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (Agency for
Health Care Administration form 3008) showed Resident #305 was incontinent, with a urinary catheter
placed on 1/12/25. The reason for the urinary catheter was urinary retention.
The physician's order dated 1/14/25 included to secure the catheter once every seven days and as needed.
The physician's order dated 1/15/25 gave instructions to administer Myrbetriq 50 milligrams once a day for
overactive bladder.
The facility's comprehensive assessment dated [DATE] listed an active diagnosis of obstructive uropathy.
On 1/27/25 at 3:48 p.m., Resident #305 was observed sitting in the wheelchair in her room. The urinary
catheter drainage bag tubing was on the floor.
The catheter was not secured to the resident's thigh resident to prevent irritation or friction. In an interview
during the observation, Resident #305 said the tubing was uncomfortable, pulls in her crotch and digs in
her skin. The resident said she really just wants the catheter out.
On 1/29/25 at 12:36 p.m., Resident #305's catheter was observed. It was not secured to the resident's thigh
to prevent movement or friction.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105363
If continuation sheet
Page 8 of 12
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
01/30/2025
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 0690
Level of Harm - Immediate
jeopardy to resident health or
safety
On 1/29/25 at 4:19 p.m., in an interview Resident #305 said she never had a urinary catheter before. She
said it was uncomfortable, and she wanted it out. The catheter tubing was not secured to the resident's
thigh. The drainage bag was under the wheelchair and resting on the floor.
On 1/29/25 at 4:26 p.m., in an interview Registered Nurse (RN) Staff G said she was taking care of
Resident #305. She said she did not know why the resident had the urinary catheter.
Residents Affected - Few
The resident's catheter was observed with the RN Staff G. RN Staff G verified the catheter was not secured
to the resident's thigh to prevent pulling and friction and verified the urinary catheter drainage bag was
stored on the floor. Staff G said the bag and tubing should not be on the floor and the catheter should be
secured to the resident's thigh for comfort.
On 1/29/25 at 4:40 p.m., in an interview Unit Manager Staff A said the resident has not had a voiding trial or
urology follow-up since being admitted to the facility. She said upon the resident's admission, she consulted
with the Advanced Practice Registered Nurse who gave the obstructive uropathy diagnosis.
On 1/30/25 at 9:06 a.m., in an interview Certified Nursing Assistant Staff K said the floor was covered with
germs, the urinary catheter bag and tubing should be off the floor at all times. She said the catheter should
be secured with a leg strap.
On 1/30/25 at 9:43 a.m., in an interview Resident #305 said she retained urine and took medication for it.
The resident said she never needed a urinary catheter before and wanted this one out. The resident said at
the hospital they told her she needed it. Resident #305 said she was able to void.
On 1/30/25 at 9:52 a.m., in an interview RN Staff H said when a resident is admitted with a urinary catheter,
the nurse should obtain a thorough medical history to determine whether the resident really needs the
catheter. Too many times, hospitals insert urinary catheters for convenience.
On 1/30/25 at 9:57 a.m., Unit Manager Staff A said the Advanced Practice Registered Nurse gave orders to
discontinue the Myrbetriq for Resident #305 and for bladder retraining. She said they would be contacting
the urologist.
On 1/30/25 at 10:09 a.m., in an interview, Minimum Data Set (MDS) Coordinator RN Staff I said she
reviewed the resident's medical record and did not see a diagnosis justifying the use of the urinary catheter.
She said she consulted with the Unit Manager and Advanced Practice Registered Nurse who gave the
diagnosis of obstructive uropathy.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105363
If continuation sheet
Page 9 of 12
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
01/30/2025
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, review of the clinical record, facility policy and procedure and resident and staff interviews, the
facility failed to maintain urinary catheters in a sanitary manner for 4 (Residents #61, # 249, #252, and
#305) of 4 residents observed with urinary catheters. The facility also failed to ensure intravenous (IV)
access devices were dated and secured properly for 2 (Resident #252, and #305) of 3 residents reviewed.
Residents Affected - Some
The findings included:
The facility policy Nursing- Catheter Care- Urinary. The purpose of this procedure is to prevent catheter
associated urinary tract infections (UTI's). Infection Control) . Maintain clean technique when handling or
manipulating the catheter, tubing or drainage bag . Be sure the catheter tubing and drainage bag are kept
off the floor.
Review of the clinical record revealed Resident #61 had a readmission date of 12/15/24 with diagnoses
including obstructive, reflux uropathy and urinary tract infection.
Record Review documented the resident's labs results were positive for a UTI (Urinary Tract Infection) on
11/6/24 and 10/21/24 and required the use of antibiotics.
The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in
nursing home residents) with a target date of 12/15/24 documented Resident #61 was dependent on staff
for all ADL's.
The MDS noted Resident #61's cognitive skills for daily decision making were intact.
The care plan initiated 9/15/24 and revised 11/1/24 identified Resident #61 had an indwelling urinary
catheter
The goals for Resident #61 specified she would be/remain from catheter related trauma and the residents
risk for urinary infections will be minimized.
The interventions included to report any signs or symptoms of UTI to the physician, provide catheter care
as ordered, and position catheter bag and tubing below the level of the bladder.
On 1/27/25 at 1:14 p.m., Resident #61 was observed in bed, and catheter drainage bag was on the floor.
Photographic evidence obtained.
On 1/28/25 at 9:35 a.m., Resident #61 was sleeping in her bed, and the catheter drainage bag was on the
floor.
Photographic evidence obtained.
On 1/28/25 at 9:37 a.m., the Registered Nurse, Staff Development Coordinator confirmed Resident #61's
drainage bag was on the floor.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105363
If continuation sheet
Page 10 of 12
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
01/30/2025
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 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Review of the clinical record revealed Resident #249 had an admission date of 1/21/25 with diagnoses
including chronic kidney disease.
The care plan initiated on 1/21/25 identified the resident has Indwelling catheter.
The goals for Resident #249 specified the resident will show no signs or symptoms of urinary infection. The
resident will be/remain free from catheter-related trauma through review date.
On 1/27/25 at 11:32 a.m., Resident #249 was observed in bed with the bed in the low position. The catheter
tubing and drainage bag were in contact with the floor.
Photographic evidence obtained.
On 1/27/25 at 00:00 Resident #249 was sent to the local emergency department and did not return to the
facility.
Review of the clinical record revealed Resident #252 had an initial admission date of 1/3/25 with
readmissions on 1/11/25 and 1/23/25 following hospitalization. Admitting diagnoses included ileostomy
(surgical opening in the abdominal wall in which part of the small intestine is brought to the surface) and
dependence on renal dialysis.
The admission MDS with a target date of 1/11/25 documented Resident #252 required substantial to
maximum assistance personal hygiene and was dependent for toileting.
The MDS noted Resident #252's cognitive skills for daily decision making were intact.
On 1/27/25 at 12:12 p.m., during an observation Resident #252's ileostomy drainage bag was attached to
the side of the bed facing the open door. There was no privacy bag, and the catheter system was visible to
anyone passing by the resident's room. The drainage bag spout was touching the metal frame of the beds
wheels.
Photographic evidence obtained.
On 1/30/25 at 10:50 a.m., in an interview Certified Nursing Assistant (CNA) Staff F said catheter drainage
bags are attached to the bed frame and the tubing and drainage bag should never be on the floor. CNA
Staff F said if the bed is in the low position, the drainage bag is placed in a wash basin to keep it off the
floor.
Review of the clinical record revealed Resident #305 was admitted to the facility on [DATE] with an
indwelling urinary catheter.
On 1/27/25 at 3:48 p.m., Resident #305 was observed in the bedroom sitting in the wheelchair. The urinary
catheter tubing was observed under the seat of the wheelchair, touching the floor.
On 1/29/25 at 4:19 p.m., Resident #305 was observed in the bedroom sitting in the wheelchair. The urinary
catheter tubing and drainage bag were observed below the seat of the wheelchair and touching the floor.
Registered Nurse Staff G confirmed the tubing and bag were on the floor. Staff G said the tubing and
drainage bag should not be in contact with the floor.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105363
If continuation sheet
Page 11 of 12
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
01/30/2025
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 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
On 1/30/25 at 9:06 a.m., CNA Staff K said the floor was covered with germs, and the urinary catheter
drainage bag and tubing should not be in contact with the floor.
The facility policy Guidelines for Preventing Intravenous Catheter -Related Infections documented The
purpose of this procedure is to maximally reduce the risk of infection associated with indwelling intravenous
(IV) catheters.Catheter Site Dressing Regimens. Change initial dressing after placement within 24 hours.
Use sterile transparent dressing.Change the transparent dressing every 5 to 7 days or as needed if .
loosened.
On 1/27/25 at 12:12 p.m., Resident #252 was observed with an IV access catheter in his left antecubital. In
an interview the resident said he thinks he was receiving antibiotics in the hospital prior to his admission at
the facility. There was no date on the dressing. The transparent dressing was rolled up on the edges.
Photographic evidence obtained.
On 1/27/25 at 4:04 p.m., the Infection Preventionist observed Resident #252's intravenous insertion site
dressing and said she was not able to tell when the dressing was changed because there was no date on
it. The Infection Preventionist said the policy for IV dressings to be changed was weekly and as needed.
Review of the clinical record revealed Resident #305 was admitted to the facility on [DATE] for rehabilitation
following surgery for an infected pacemaker. The physician ordered an IV antibiotic on 1/14/25 to be given
daily every 2 days until 2/20/25.
On 1/14/25, the physician ordered a dressing change to the IV catheter insertion cite to be completed on
admission or 24 hours after insertion and weekly thereafter and as needed.
Review of the medication administration record revealed the nurse signed off the IV cover dressing was
changed on 1/21/25.
On 1/27/25 at 3:48 p.m., during an observation of Resident #305's IV cover dressing, the date handwritten
on the dressing was 1/17/25.
Photographic Evidence Obtained
On 1/27/25 at 4:05 p.m., in an interview the Infection Preventionist, verified the IV cover dressing was dated
1/17/25 and was outdated. She said the IV dressing should be changed every seven days to prevent
infection.
On 1/27/25 at 5:10 p.m. during an interview RN Staff J said she administered the IV antibiotic to Resident
#305 today with the outdated cover dressing. She said the Medication Administration Record did not trigger
her to check the date and she did not notice it was outdated.
On 1/30/25 at 11:50 a.m., in an interview the Infection Preventionist said the nurse who signed off the
dressing change was completed on 1/21/25 should not have signed off something that was not done. She
said the IV dressing was outdated.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105363
If continuation sheet
Page 12 of 12
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
5 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.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the January 30, 2025 survey of CHARLOTTE BAY REHAB AND CARE CENTER?
This was a inspection survey of CHARLOTTE BAY REHAB AND CARE CENTER on January 30, 2025. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CHARLOTTE BAY REHAB AND CARE CENTER on January 30, 2025?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide care and assistance to perform activities of daily living for any resident who is unable."
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.