Health inspection·February 25, 2025

F 0689 of absence with responsible party. Level of Harm - Minimal harm or potential for actual harm Review of the Rehab Speech Screen dated 10/29/24 revealed documentation Resident #1 presented with, baseline speech, language and cognitive deficits. Poor participation during eval . Pt (patient) also stated, I want out of here. Residents Affected - Few On 11/3/24 the Social Worker initiated a care plan indicating Resident #1 had impaired cognitive function/dementia or impaired thought processes related to short term memory loss. Interventions included to cue, reorient and supervise the resident as needed. The elopement evaluation dated 1/24/25 noted Resident #1 was cognitively impaired and had poor decision-making skills. Resident #1 did not have the ability to leave the facility. The evaluation noted the resident had no exit seeking behaviors and was not at risk of elopement. Review of the progress notes revealed an entry dated 2/19/25 that read, Elopement Risk- Wander guard in place. (Alerts staff when a resident leaves a designated safe area). The progress note did not explain the reason for the wander alert bracelet. On 2/19/25 Resident #1's care plan was updated and noted the resident was an elopement risk/wanderer related to impaired safety awareness. The goal was to maintain the resident's safety. The interventions included checking the placement and function of the wander alert bracelet. On 2/25/25 at 9:53 a.m., in an interview the Maintenance Director said on 2/19/25 Assistant Director of Nursing (ADON) Staff B found Resident #1 outside, on the sidewalk near C wing. ADON Staff B notified the Director of Nursing (DON) and followed the resident in her car. He drove the DON in his car and dropped her off a few streets away from where Resident #1 was. The Maintenance Director said the front door opens at 8:00 a.m., and Resident #1 probably went out that door and then around the building. On 2/25/25 at 9:55 a.m., in an interview ADON Staff B said on 2/19/25 she arrived in the parking lot of the facility at approximately 8:30 a.m. She saw Resident #1 coming out the door located on the side of building by the C wing. The door was open, but she did not hear an alarm going off. When she pulled into the parking space, she realized Resident #1 was leaving the parking lot in his electric scooter. He did not stop and began crossing the road. ADON Staff B said physically she was not able to get to the resident on foot. She got back in her car, called the DON and followed Resident #1 in her car. Resident #1 had crossed the road and was on the sidewalk. He went down the street to the curve by a restaurant, turned right on a street, then left on another street. She said she followed Resident #1 to keep him safe while talking on the phone to the DON. ADON Staff B said she finally got him to stop. She asked him where he was going, and if he had signed out. Resident #1 responded he just wanted to get out for a little while. The DON arrived by car with the Maintenance Director. The DON walked with Resident #1 back to the facility. ADON Staff B said she has had training in elopement. To her understanding, an elopement was when a resident is outside the building without staff knowledge. ADON Staff B said Resident #1 exited the facility through a door equipped with a wander alert alarm. Resident #1 did not have a wander alarm bracelet; therefore, the door would not have alarmed. On 2/25/25 at 10:53 a.m., in an interview the Maintenance Director said he didn't know if Resident #1 exited the building through the side door. He said the side door has an alarm which he checks the function every day. He said once the alarm is activated, a pass key is needed to turn off the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105363 If continuation sheet Page 2 of 4 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 02/25/2025 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 alarm. He said no one told him there was a problem with the alarm of the side door. Level of Harm - Minimal harm or potential for actual harm On 2/25/25 at 10:11 a.m., the C wing door was observed with the Administrator. The Administrator explained the first door can be opened by pushing a green button. The second door can only be opened by punching a code or pressing on the egress bar for 15 seconds. However, when the egress bar releases, it will activate an alarm. Residents Affected - Few On 2/25/25 at 10:40 a.m., in an interview the DON said on 2/19/25 at around 8:20 a.m., ADON Staff B called her and said she was watching Resident #1 going down the road. The ADON told her where Resident #1 was. She stayed on the phone with the ADON until she got to where the resident was. The ADON got the resident to stop. She walked him back to the facility. The DON said she was not familiar with Resident #1. He said he was getting air. The DON said she verified Resident #1 did not sign out before leaving the facility. She said Resident #1's scored a 07 on the Brief Interview for Mental Status (a score of 07 or below indicated severe cognitive impairment). She said Resident #1 had no prior attempt to leave the facility. After the incident, they updated the resident's care plan and initiated a wander alarm. She said they really did not know through which door the resident exited the building. She spoke to a few staff members at the time of the incident but did not do a formal investigation. She reported the incident to the Regional Nurse since the Administrator was on vacation. She said she did not consider the incident an elopement since ADON Staff B followed the resident in her car the entire time. On 2/25/25 at approximately 10:45 a.m., the side door by the C wing was observed with the DON. The DON pushed the green button and opened the first door. She pushed the egress bar on the second door for approximately 15 seconds. The door opened and the alarm went off. The Minimum Data Set (MDS) nurse responded to the alarm and said the door will continue to alarm until it is turned off with a key. On 2/25/25 at 10:58 a.m., in an interview the Regional Nurse verified the DON notified her when Resident #1 left the faciity on 2/19/25. She said no investigation had been done. She did not consider the incident to be an elopement. She said ADON Staff B followed Resident #1 in the car and would have been able to stop him from getting hit by a car or involved in any type of accident. On 2/25/25 at 12:00 p.m., observation of the route taken by Resident #1 on 2/19/25 showed the resident crossed two streets and traveled approximately 0.3 miles from the facility when ADON Staff B was able to get him to stop. On 2/25/25 at 2:25 p.m., in an interview the Speech Therapist said during the first assessment on 10/29/25 Resident #1 scored 07 on the BIMS. She said it indicated severe cognitive deficit, but the resident was not participatory, and it was not a true picture of his cognition. She said he got the electric scooter on 2/5/25. Occupational Therapy evaluated him and determined he was safe to use the scooter. Review of the Occupational Therapist progress note dated 2/12/25 revealed documentation the resident needed distant supervision with use of personal power wheelchair in facility and outside of facility on sidewalk and sitting areas. The resident has been instructed each session on safety rules and facility protocols with resident knowing he is not allowed in parking lot or off facility grounds. Overall it is recommended resident be distant supervision with use of personal power chair in order to provide the resident with as much independence during the day as possible. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105363 If continuation sheet Page 3 of 4 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 02/25/2025 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 - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 2/25/25 at 3:50 p.m., in a telephone interview the Psychiatric Advanced Practice Registered Nurse (APRN) said she had seen and assessed Resident #1. She said Resident #1's cognition was not that great, and he was child-like. He was not able to be on his own and leave the facility on his own. On 2/25/25 at 4:40 p.m., a meeting was held with the Administrator, the DON and the Regional Nurse. The DON verified Resident #1's cognition was severely impaired and verified an elopement evaluation was not done when the resident started using the electric scooter. The Administrator said Resident #1 could have left through the front door and proceeded around the building, but they did not know and did not investigate. He said they would look into the incident and develop a plan to prevent further occurrences. Event ID: Facility ID: 105363 If continuation sheet Page 4 of 4