Health inspection·May 8, 2025

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 observations, record review, resident and staff interviews, the facility failed to implement appropriate interventions, including adequate supervision to prevent falls for 2 (Residents #1 and #4) of 4 residents reviewed with multiple falls and/or fall related injuries. The findings included: 1. Review of the clinical record for Resident #1 revealed an admission date of 9/7/23. Diagnoses included but were not limited to generalized muscle weakness, difficulty in walking, lack of coordination, repeated falls, abnormalities of gait and mobility, severe dementia with other behavioral disturbances. Review of the Annual Minimum Data Set (MDS) assessment with a target date of 9/9/24 revealed the resident's cognition was severely impaired with a Brief Interview for Mental Status score of 03. Resident #1 required supervision to walk 10 feet and was independent to wheel herself 50 feet once seated in the wheelchair. Review of the care plan initiated on 9/15/23 and last reviewed on 10/14/24 revealed Resident #1 was at risk for falls related to deconditioning. The goal was for the potential for falls/fall-related injuries to be minimized through the next review date. The interventions included but were not limited to anti rollback to the wheelchair (4/26/24), nonskid pad to wheelchair (7/16/24), encourage resident to wear appropriate nonskid footwear (10/06/23). Resident #1's care plan initiated on 6/17/24 noted the resident had a behavior problem related to anxiety and depression. Resident noted with placing herself on to floor. The goal was for the resident to have fewer episodes. The interventions included but were not limited to anticipate and meet the resident's needs, assist the resident to develop more appropriate methods of coping and interacting. Review of the incident history log revealed Resident #1 was found on the floor four times in 2023, five times in 2024, and once on 2/8/25. The log noted Resident #1 had a witnessed fall Unassisted once in 2023, once in 2024 and on 1/5/25. Review of the progress notes revealed on 1/5/25 at 6:55 p.m., Resident #1 had a witnessed fall. Page 1 of 6 105524 105524 05/08/2025 Port Charlotte Rehabilitation Center 25325 Rampart Blvd Port Charlotte, FL 33948

F 0689 Level of Harm - Actual harm Residents Affected - Few Certified Nursing Assistant (CNA) Staff A witnessed the fall and stated that the resident was agitated and screaming. She attempted to transfer her back to her room via wheelchair from the 400 hall. The resident's left foot got stuck under the left wheelchair wheel. Resident #1 ended up falling and hitting her head with the floor. CNA Staff A started calling for help. The resident was facing down and blood was coming from her face. At the time of the assessment, a laceration was noticed to the resident's forehead and the resident's nose was bleeding. Pressure was applied to the forehead laceration and the nosebleed stopped. Resident #1 was sent to the local emergency room for evaluation. The progress note dated 1/5/25 at 10:50 p.m., noted Resident #1 was received from the hospital with diagnoses of multiple rib fractures of left side and closed nose fracture. Review of the facility's investigation report revealed an Interdisciplinary Team Summary noting on January 5, approximately 6:55 p.m., Resident #1 was self-propelling down the hallway as per her usual. Interview with the CNA involved in the incident indicates that she noted Resident #1 on the unit she was working and thought to return the resident back to her own unit. As she was transporting her back to her unit, Resident #1 planted her feet onto the floor which is not a normal behavior for her. In doing so, this action caused Resident #1 to fall forward and hit the ground sustaining a nasal and rib fracture. The investigation report noted the possible contributing factor was the resident's behavior, agitated. The predisposing factor included dementia and vision problems. The description of the incident noted CNA (Staff A) witnessed the fall and stated that the resident was agitated and screaming. She attempted to transfer her back to her room via wheelchair from the 400 hall, when the resident's left foot got stuck with the left wheelchair wheel, ended up falling and hitting her head with the floor. The report noted the resident was wearing sock and slippers. The report did not document if the resident's legs and feet were placed on footrests in the wheelchair during the transport. On 5/8/25 at 10:14 a.m., a meeting was held with the Director of Nursing and the Regional Nurse Consultant to discuss Resident #1's falls. The Director of Nursing (DON) said in October 2024 Resident #1 sustained a fall at the nursing station. She was at the nursing station with a nurse. The nurse heard someone fall and went to attend to the fall. When she came back to the nursing station, Resident #1 was on the floor. She sustained a fracture of her nose. The DON verified on 1/5/25 at approximately 6:55 p.m., Resident #1 fell from the wheelchair and sustained a nasal bone and left ribs fractures. The DON said the resident had anti rollbacks to the wheelchair (Helps prevent falls from wheelchair by automatically locking the wheels when the resident begins to stand). The Regional Nurse present during the interview said the CNA's hand was on the resident's shoulder. The resident turned and slid off the chair. The CNA tried to catch her but couldn't. The Regional Nurse said as part of their investigation, they looked at the film from the cameras in the hallway. The DON said the film was no longer available to review as it periodically erases to record new 105524 Page 2 of 6 105524 05/08/2025 Port Charlotte Rehabilitation Center 25325 Rampart Blvd Port Charlotte, FL 33948

F 0689 information. Level of Harm - Actual harm When asked about Resident #1's positioning of her legs and feet during transport with the wheelchair, the DON said the wheelchair had no footrests. She said Resident #1's son did not want the footrests on the wheelchair. Residents Affected - Few The DON verified there was no care plan in place for the lack of footrests in the resident's wheelchair for safe transport. She said she should have documented it. On 5/8/25 at 11:45 a.m., in an interview the Director of Rehab said Resident #1 was on a functional maintenance program to prevent decline. She said Resident #1 used a propelling motion a lot when sitting in a wheelchair. On 1/5/25 they placed a nonslip mat on her wheelchair. They were thinking about dumping the chair meaning lowering the seat of the wheelchair. The resident could still transfer but it would prevent her from falling. She said they most likely lowered the wheelchair after a fall but did not have an exact date. Further review of the clinical record revealed on 2/8/25 at 6:05 p.m., Resident #1 was verbally and physically disturbing others and shouting loudly, disturbing the peace of other residents throughout the whole building. On 2/8/25 at 7:58 p.m., a progress note documented Residents were unable to sleep due to the constant disturbances of Resident #1's behaviors. Resident #1 continues to purposely slide out of the chair. Review of the investigation reports revealed on 2/8/25 at 8:00 p.m., Resident #1 was found on the floor and sustained a discoloration. The precipitating factors included: Agitated and getting up from wheelchair or sitting position. Contributing factors included unsteady gait, agitation, yelling, crying, grabbing people and a recent medication change. The Interdisciplinary Team Summary noted Resident #1 was reviewed for a fall on 2/8/25 at 8:00 p.m. The Registered Nurse working at the time of the occurrence indicated the resident had been self-propelling around on the unit prior to being observed sitting on the floor in front of her wheelchair on her butt on hall 600. The investigation noted the seat to the resident's wheelchair has been dropped to prevent further occurrences. The investigation noted the current care plan was in place. The investigation did not include interventions, such as adequate supervision when the resident was agitated and continued to purposely slide out of the chair. On 5/8/25 at 12:05 p.m., the DON said after the fall on 2/8/25, that's when they dumped the chair. She said they did a lot for Resident #1 but did not take credit for it. She said on 2/8/25 the nurse got called away because something else required her attention. Resident #1 got agitated and she fell. She said, in a realistic world you cannot expect the nurses to document every time, every intervention. She said she wishes she would have kept a diary because it was a daily battle. 105524 Page 3 of 6 105524 05/08/2025 Port Charlotte Rehabilitation Center 25325 Rampart Blvd Port Charlotte, FL 33948

F 0689 The Regional Nurse said at times, they provided one to one supervision for Resident #1. Level of Harm - Actual harm Resident #1 was transferred to the hospital on 3/5/25 and has not returned to the facility. Residents Affected - Few 2. Review of the clinical record for Resident #4 revealed an admission date of 3/18/25. Diagnoses included debility. Review of the admission MDS with a target date of 4/1/25 revealed the resident's cognition was moderately impaired with a BIMS score of 11. Resident #4 had functional limitation of range of motion on both upper extremities. Resident #4 was dependent on staff for sit to stand. The MDS noted the care areas assessments addressed in care plans included falls, cognitive loss/dementia. The fall risk assessment completed on 3/18/25 noted Resident was disoriented times 3 (Person, place and time) all the time, had a history of one to two falls in the past three months, ambulation and elimination source noted: Ambulation/Chair bound/Incontinent. Resident 34 had balance problem while standing/sitting/walking. One to two Predisposing conditions. The fall risk score was 20. The form noted a fall risk score equal to or greater than 8 indicates a possible fall risk. The admission evaluation dated 3/18/25 noted Resident #4 had a history of falls. The summary noted Resident #4 was a fall risk, multiple attempts to slide out of bed. Review of the care plan showed a care plan indicating Resident #4 was at risk for falls related to gait/balance problems and incontinence was initiated on 4/2/25 with a revision on 4/28/25. The care plan noted it was reviewed on 3/31/25 (before initiation), 4/2/25, 4/3/25, 4/17/25, 4/24/25, and 4/27/25. The goal was to minimize the potential for falls/fall related injuries. The interventions as of 4/2/25 noted fall mats while in bed. On 5/8/25 at 10:25 a.m., Resident #4 was observed walking in the bathroom. A fall mat was observed on the floor to the right side of the bed. ¼ rails were in the up position at the head of the bed. In an interview, Resident #4 said she got out of bed unassisted to go to the bathroom. On 5/8/25, review of the incident log and progress notes for Resident #4 revealed the resident sustained eight falls at the facility from 3/31/25 through 4/27/25. On 5/8/25 at 2:35 p.m., a meeting was held with the DON to discuss Resident #4's multiple falls, fall investigations and interventions to prevent recurrence. Review of the progress notes revealed: On 3/31/25 at 7:30 a.m., Resident #4 was observed on the floor laying on her back underneath the bed. The resident complained of left hip and lower back pain. Resident had nonskid sock on and call light was not on. Resident was assisted safely back to bed. 105524 Page 4 of 6 105524 05/08/2025 Port Charlotte Rehabilitation Center 25325 Rampart Blvd Port Charlotte, FL 33948

F 0689 The care plan was updated on 3/31/25 with a scoop mattress (mattress with raised border to help stop the resident from sliding out of bed). Level of Harm - Actual harm Residents Affected - Few The DON said the root cause of the fall was Resident #4 was trying to get out of bed on her own. She lacked safety awareness and was unaware of her own limitations. She could not explain why she fell. On 4/2/25 at 1:20 a.m., Resident #4 was observed sitting on the floor on the right side of the bed with legs stretched out in front and back against the bed. Resident #4 did not sustain any fall related injury. The progress note documented, Resident has been a frequent check related to the previous fall. Frequently need to reposition related to resident hanging legs off the right side of the bed. The nurse had left the room [ROOM NUMBER] minutes earlier. Resident #4 was assisted back to bed with the assistance of three people. On 4/2/25 the care plan noted interventions to use fall risk screen to identify risk factors, encourage the resident to use the call light for assistance as needed, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. On 4/3/25 at 6:00 a.m., Resident was found lying on the bedside mat on the floor alongside the bed. Skin tears noted to upper extremities, two on each arm, no other injuries noted. Resident #4 was assisted back to bed. The skin tears were cleansed and dressed. An abrasion was obtained as a result of the fall. On 4/3/25 at 7:56 p.m., Resident #4 was observed laying on the floor alongside of the bed, unable to express what happened. No overt signs or symptoms of injury were noted. The bed was in the lowest position, fall mat in place. The note documented the resident was checked frequently for safety. The DON said the resident was unable to express what happened. She had been restless and unable to use the call light. The primary nurse saw her on the floor. When asked about the CNA statement as part of the investigation, the DON said there was no CNA statement. On 4/3/25 at 10:30 p.m., Resident was observed laying on the floor alongside of bed. Unable to express what happened. No signs or symptoms of injury noted. The bed was in the lowest position, fall mat in place. The resident was placed in a Broda chair (reclining chair that can assist in fall prevention) and moved to the nurses station for safety. On 4/3/25 the care plan was updated with low in lowest position while in bed, remove air mattress, labs. The care plan noted the interventions were initiated on 4/4/25. The DON said the CNA had assisted the resident with toileting needs one hour prior. She had very restless behavior. They scheduled her for labs, including a urine analysis due to her mentation. She said the CNA had seen her within the hour and that was close supervision. On 4/17/25 at 9:20 a.m., Resident #4 was heard calling out in her room. Housekeeping went in her room and found resident sitting on the floor in the bathroom. The nurse went in the room and observed Resident #4 sitting on her bottom, both legs stretched out in front of her. Resident stated she was trying to take herself to the toilet and slipped out of the wheelchair. Resident voiced neck pain once back in her wheelchair. She said she had chronic neck pain. 105524 Page 5 of 6 105524 05/08/2025 Port Charlotte Rehabilitation Center 25325 Rampart Blvd Port Charlotte, FL 33948

F 0689 On 4/17/25 the care plan was updated with Occupational Screen and resident to be placed in high visual areas. The date initiated was 4/18/25. Level of Harm - Actual harm Residents Affected - Few On 4/24/25 at 6:07 a.m., Resident #4 was observed sitting on the floor with her back against the bed. Fall mat was folded and sitting on her right. Nonskid socks were removed and sitting next to the bed, the bed was in the lowest position. Resident #4 stated she got up and walked to the closet and lost her balance and stumbled backward into a sitting position with her back against the bed. The resident denied pain or injury and was assisted back to bed. On 4/24/25 the care plan was updated with early riser list. On 4/27/25 at 1:00 a.m., Resident #4 was observed on the floor at the foot of the bed, near the window, laying on her right side facing the window. Resident #4 stated she got up to go to the bathroom, lost her balance (the bathroom was in the opposite direction). Resident #4 had a large bruise on her right ischium but denied pain. Resident #4 also stated she bumped her right forehead and right shoulder during the fall. No visible marks but has some discomfort with palpation around the shoulder. The resident exhibited/expressed localized bruising, swelling, or pain over joint or bone as a result of the fall. On 5/8/25 at 3:10 p.m., Resident #4 was observed in bed. ¼ rails were up at the head of the bed. No fall mats were observed on the floor next to the resident's bed. On 5/8/25 at 3:12 p.m., in an interview CNA Staff B verified no fall mats were on the floor as per the care plan. She said Resident #4 gets out of bed on her own and said, Maybe I should remove them. On 5/8/25 at 4:13 p.m., a meeting was held with the Administrator and DON to review the facility's Quality Assurance and Performance Improvement (QAPI) program related to fall prevention. The observation of a fall mat next to Resident #4's bed when the resident was out of bed and said she got out of the bed on her own and observation of Resident #4 in bed with no fall mats on the floor were shared with the DON. The DON said Resident #4 had improved and she should not be having fall mats as it is a trip hazard. She verified the care plan still listed the fall mats as an intervention to minimize fall related injuries and said Resident #4 in bed without the fall mats was shared with the DON. She said Resident #4 should not have fall mats while in bed as she is able to get out of bed on her own and it should have been removed from the care plan. The DON said she conducted education on fall strategies during nursing meetings on 2/24/25, 2/25/25, and 2/26/25. The Administrator said they added a lead CNA in the morning in halls 300, 400, 500 and 600. The CNA provides added support on the floor, assists the other CNAs. She can help do impromptu check ins with the residents and provides customer service. The program was initiated within the last 30 to 45 days. Several therapists are getting a certification in fall prevention. The DON said she had an action plan that she will present at the next QAPI meeting. 105524 Page 6 of 6