Inspection·April 16, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and medical record review, the facility failed to notify the resident representative of significant changes for two (Resident #4 and Resident #6) of 4 residents reviewed for significant changes. The findings included: The facility policy issued 5/2017 and revised 6/2023 for Change in Resident Condition or Status - Resident Rights Standard states the facility shall notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status. Resident #4 was admitted to the facility on [DATE] from the hospital for rehab after Urinary Tract Infection and Cerebrovascular Accident. Her BIMS (Brief Interview for Mental Status) was 99 which indicates resident not cognitively intact. A skin check dated 3/7/24 in Resident #4's medical record read Stage 3 Pressure Injury 90% slough and 10% granulation tissue noted with moderate amount serosanguinous drainage with no odor, defined wound edges, erythema noted to peri wound, no noted tunneling, sinus tracking, or undermining. No s/s (signs or symptoms) of infection noted at this time. Resident unable to rate pain but verbalizes pain during cleansing. Treatment placed. Resident repositioned on side. There was no change in condition or notifications found for the pressure wound development in Resident #4's medical record at that time. On 4/16/24 at 12:48 a.m., in an interview Staff A, RN (Registered Nurse), accompanied by The Director of Nursing (DON) said her initial exam of Resident #4 was on 3/7/24 when she first discovered the pressure wound to her sacrum. She put in a consult to wound care at that time. She said the daughter was visiting her mother during wound care rounds on 3/11/24 and she notified her of the pressure wound at that time. She documented this in nurse progress notes. She said she notified the daughter of the new pressure wound and treatment plan. Per the DON, any wound/pressure wound would be considered a significant change in condition. She said notifications to the family should be made for all changes in conditions. Progress notes documented on 3/11/24 by Staff A showed This nurse and wound Nurse Practitioner rounded on resident. Resident has unstageable pressure injury to her sacrum. (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: 105523 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 105523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 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)