Health inspection·July 8, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few moderate assistance with bed mobility and hygiene. The MDS noted the resident scored 8 on the Brief Interview for Mental Status, indicating the residents' cognitive skills for daily decision making were moderately impaired.On 7/8/25 at 8:45 a.m., in an interview Resident #899 said a Certified Nursing Assistant (CNA) grabbed the call light out of her hand. She said she did not know the name of the CNA but she was very strong. Resident #899 pointed to her left hand. Dark bruising was observed on the dorsal area of the resident's left hand, and the palmar area of the 4th and 5th fingers.Resident #899 said, She (the CNA) was angry and was very strong. I was very upset that day about it. I think I was telling her to stop when she was trying to get the call light out of my hand, and she let up after a couple of minutes. It happened so fast, I think I was yelling. She was trying to get the wires out of my hand, and I was being grabbed. I don't know why she was trying to take it from me. They removed her and she has not been back since. When I use the call light now, they come. The facility did an x-ray and they took pictures of my hand and I have a fractured finger on the pinky finger of the left hand.The resident said, I felt and still feel when caring for people who have disabilities that you should treat them well.On 6/25/25 the Physician documented in a progress note, Chief Complaint: Per nursing, left small finger swelling and pain, and abdominal rash. The nurse reports today that there is some swelling and pain of the left little finger. Apparently, the patient is reporting that her hand may have been twisted and states she was trying to use a remote by a caregiver. When seen in her room, she was enjoying an eclair dessert using her left arm. There is swelling and an area of ecchymosis (bruising). She said that she did have some pain with movement but was able to use her hand. Otherwise, she was alert and enjoying her desert. She does have some forgetfulness. The left hand particularly the left fifth finger has an area of ecchymosis, tracking down to the left anterior hands with evident swelling. There was decreased range of motion. No gross dislocation. She was able to do some range of motion. The wrist has full range of motion including the elbow and she was able to raise her left upper extremity. Alert and oriented x I to 2, oriented to self with some confusion. Assessment: Left fifth finger swelling ecchymosis. Generalized weakness. Lung cancer with brain metastasis. Plan: Ordered stat (without delay) x-ray of the hand, focusing on the left fifth finger to see. She was wanting to use her left hand. Will await results. I did meet the POA (Power of Attorney) in the hallway and I did report that x-ray was being done. I did ask the nurse to call Director of Nursing (DON) to report incident at this time.Review of Resident #899's left-hand x-ray obtained 6/25/25 revealed an acute mildly displaced fracture of the fifth finger.On 7/8/25 at 10:12 a.m., in an interview CNA Staff A said on 6/25/25, she was asked to get Resident #899 up and dressed for a care plan meeting. CNA Staff A said, That day I saw her hand bruised. I told the nurse, the DON came and spoke to me. She said the resident was confused and always grabs the side rail when you turn her, and she yells. CNA Staff A said The resident holds the side rail so tight, she could have hit her hand on it, and she moves her hands around, maybe she hit something. I never tried to take the call light from her, it is my job to give it and answer it. The CNA said she always puts the bed down when she is done providing care and always gives the resident the call light, the bed control, the table and remote control for the television.CNA Staff A said, The resident's friend came to visit on 6/25/25, and showed me her hand and I told the nurse. They gave me education in person and in writing on abuse. I never tried to take the call light from her, I don't know why she says that.A follow-up observation of Resident #899's bed noted there were no side rails attached to the bed.On 7/8/25 at 2:26 p.m., in a telephone interview LPN Staff B said on 6/25/25 she was working the day shift and went to give Resident #899 her medication.She said, The resident told me a nurse came in last night and twisted her hand. Her left hand was swollen, and she had bruising from the left pinky to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105538 If continuation sheet Page 2 of 3 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 105538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harbour Health Center 23013 Westchester Blvd Port Charlotte, FL 33980 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 0600 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete wrist. I don't think she can tell the difference between a CNA or a nurse but I believe she can tell you what happened to her. I notified the supervisor and called the doctor. The Abuse person is the Administrator, so I told him too.On 7/8/25 at 1:05 p.m., in an interview the Administrator verified he was the abuse coordinator for the facility. He said he spoke with Resident #899's Health Care Surrogate after the incident. He said, I spoke to her in person but did not take her statement, she seemed exhausted, and she spoke to the police department at length. I did not get a copy of the police report.The Administrator said the root cause of Resident #899's injury was, We determined the cause with the primary care physician, and we could not determine if the cause was forceful. The physician thought the fracture would be splintered if it was abuse. We checked to see if she hit her hand on something. We could not rule out that it was trauma. The Physician said it could have happened by bumping it on something. Ultimately, we could not pinpoint the cause of the fracture itself. He said CNA Staff A does not have access to the resident; she is not allowed in her room. He said the CNA is supervised on each shift so the Supervisor will ensure the CNA is not going in the room. The Supervisor will ensure that they are providing care in pairs.On 7/8/25 at 2:20 p.m., in an interview the Medical Director said she was aware of the incident with Resident #899's fracture. She said, I saw her right after, and she had swelling and bruising to the left hand. I figured some type of trauma occurred and ordered a STAT X-ray. The X-ray showed demineralization which means the bone is thin and there was a fracture of the 5th finger. The resident is very frail. She has lung cancer with metastasis (spreading) to the brain and the bone. She has some confusion, and she did tell me the aid tried to grab the call light out of her hand. It is up to the facility to investigate it and see what happened. The resident was seen last week, and she had no pain, the bruising was there but the swelling was gone. I did not want to order any splint because she could move the fingers and she was feeding herself. The injury could be you could bang it. It was some kind of trauma because there was swelling and bruising. The fracture was caused by trauma, but what, I don't know. The resident has some confusion but she has some thought and insight.On 7/9/25 at 5:07 p.m., in a telephone interview Resident #999's friend said she saw Resident #899 the day before the incident and her left hand was fine. There was no swelling or bruising. The next day she came again and her left hand was swollen and bruised. Resident #899 said they tried to take the call light from her hand and that is how she hurt her hand. She said the person twisted her hand trying to get the call light.The friend said she was not there when it happened but she did not have any injury the day before. She let the nurse know. The DON came and spoke with me. The police were notified and she spoke to them for a long while. Event ID: Facility ID: 105538 If continuation sheet Page 3 of 3